Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulmonary rehabilitation.
You asked the Plan to pre-approve these services. You say that you have shortness of breath and feel heavy when moving. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease. The services must be provided in a doctor's office or an outpatient hospital setting. The PR program must include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have chronic shortness of breath of uncertain cause. The workup was negative for pulmonary disease, no issues on imaging, and no active cardiac disease. You do not have chronic obstructive pulmonary disease (COPD) or any other qualifying lung disease for which pulmonary rehab is covered. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve pulmonary rehabilitation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira 40 mg / 0.4 ml syringes.You asked the Plan to pre-approve Humira. You say that the Humira is medically necessary.The Plan denied your request. The Plan says the drug is self-administered. Self-administered drugs are not eligible for coverage under Part B medical benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Humira 40 mg / 0.4 ml syringes.Benefits for Humira may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 19, 2019 through August 26, 2019 and August 26, 2019 through September 4, 2019.
You asked the Plan to waive the copayment for the inpatient stays. You say that you have only ever had one copayment. You say that you cannot afford two copayments. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 copayment per day for days 1 through 7. You pay nothing per day for days 8 through 90. Your contract with the Plan clearly says that your inpatient cost share will begin the first day of each inpatient admission or each transfer to another facility. You have been asked to pay a $1,890 copayment for the inpatient stay provided from August 19, 2019 through August 26, 2019. ($270/day x 7 days = $1,890). You have also been asked to pay $1,599.98 for the inpatient stay provided from August 26, 2019 through September 4, 2019, which is less than the standard copayment because you met your out-of-pocket maximum. The total amount you owe is $3,489.98 ($1,890 + $1,599.98 = $3,489.98).
The inpatient stays fall within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 19, 2019 through August 26, 2019 and August 26, 2019 through September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 implants (D6010), the bone graft at the time of an implant placement (D6104), and the guided tissue regeneration (D4266) provided on September 3, 2019.
You asked the Plan to pay for the 2 implants, the bone graft, and the guided tissue regeneration. You say that the extraction should be approved. The Plan denied your request. The Plan says the services you received are not covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2 implants (D6010), the bone graft at the time of an implant placement (D6104), and the guided tissue regeneration (D4266) provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular partial denture.You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that you did not receive any dentures within 60 months.The Plan denied your request. The Plan says these services are allowed one time every 60 months. The Plan also says that the records show that you received these services less than 60 months ago.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to once every 60 months. The record shows that you received a complete maxillary denture and mandibular partial denture on February 12, 2018 and your dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture and mandibular partial denture
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on August 8, 2019.You asked the Plan to pay for hospital discharge day management. You say that this claim was coded correctly.The Plan denied your request. The Plan says this claim was not billed with the necessary diagnosis codes.The Plan follows Medicare rules. Medicare rules say that when using 7th character "S", it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for hospital discharge day management. Our reviewer says that this claim was not billed with the injury associated with the sequela. Our physician reviewer found based on the medical records received the traumatic ischemia of muscle was due to a fall and not either of the other diagnoses listed on the claim: hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (I12.9) or chronic kidney disease, stage 3 (N18.3).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Specifically, the sequela was identified with a 7th character S. The claim form did not sequence the injury associated with the sequela in this case.Therefore, we decided that the Plan does not have to pay forhospital discharge day management (99239) provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on August 23, 2019.You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation providedon August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Etonogestrel contraceptive implant system provided to the enrollee on September 19, 2019.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. The rules say that, with the exception of a limited number of preventive services specifically listed as covered, Medicare does not cover items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The services at issue are an Etonogestrel contraceptive implant system. Medicare does not cover contraceptive drugs as a preventive service.Therefore, we decided thatthe Plan does not have to pay forthe Etonogestrel contraceptive implant system provided to the enrollee on September 19, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and 5 additional periapical x-rays (D0230) provided on September 3, 2019.You asked the Plan to pay for the oral hygiene instructions and periapical x-rays. You say that you should not have to pay for the services that were not explained to you. You also say that you have a low income status.The Plan denied your request. The Plan says oral hygiene instruction and periapical x-rays are not listed as covered services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the oral hygiene instruction and periapical x-rays are not among those covered under this benefit. The record shows that the Plan contacted the provider's office and they advised that they wrote off the charges for these services leaving your responsibility at $0.Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and 5 additional periapical x-rays (D0230) provided on September 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (99232) provided on September 4, 2019.You asked the Plan to pay for the hospital. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says the claim must be submitted to the enrollee's commercial policy first.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an Explanation of Benefits issued by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the hospital until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for hospital services (99232) provided on September 4, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis (L1833) provided to the enrollee on August 7, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis (L1833) provided to the enrollee on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided October 4, 2019.You asked the Plan to pay forthe orthosis. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence ofa prior telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 22, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services rendered on July 22, 2019 were denied as the Plan requested a copyof the primary payer's Explanation of Benefits in order to coordinate benefits for claim processing. The Plan says they did not receive the requested information. The Plan says the records indicate the enrollee was not enrolled with Medicare being the primary payer on the date that would obligate the Plan to cover the disputed service.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means thatthe Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an Explanation of Benefits from the primary payer. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the post and core in addition to crown, indirectly fabricated, (D2952) provided on April 8, 2019 by the out of network provider.
You asked the Plan to pay for the dental service. You say that the services you received were a continuation of services you received in 2012 from another provider who has since retired. You say that you received a postcard from the dental office as a reminder to complete the dental work. You say that you decided to get the work done. The Plan denied your request. The Plan says the post and core in addition to crown is not listed as a covered service. The Plan also says that the provider in this case is out of network. The Plan also says that services received out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the post and core in addition to crown, indirectly fabricated, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the post and core in addition to crown, indirectly fabricated, (D2952) provided on April 8, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 13, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that there was no diagnostic testing for the colonoscopy. You say that this shouldn't cost you $350. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery in an in-network outpatient hospital facility. You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered due to rectal bleeding, which is considered diagnostic. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 13, 2019.