Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic or therapeutic injection (62323) provided on July 28, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $250 copayment for the Medicare-covered outpatient procedure provided at an ambulatory surgical center. 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 diagnostic or therapeutic injection (62323) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2950, D3330, D9944).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D2950, D3330, D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision care services provided to the enrollee on June 30, 2020.
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your request. The Plan says prior authorization was not obtained.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve vision care services provided to the enrollee on June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided
September 24, 2020 to September 29, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the charges
were fraudulent. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $325
per-day copayment for days 1-6 for inpatient care.
You have been asked to pay a $1625.00 copayment for 5 days of inpatient rehabilitation services. The inpatient
rehabilitation services fall within the inpatient 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 inpatient rehabilitation services provided September 24, 2020 to September 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (CPT 99285) provided to the enrollee on May 28, 2020.
You asked the Plan to pay for the services. You say that the services have been accurately reported and submitted using the appropriate CPT codes. The Plan denied your request. The Plan says this did not include the appropriate primary, first-listed or principal diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity." 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found ICD-10 T50.905A -Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter is a secondary diagnosis, and would be inappropriate to report as primary. Per the ICD-10 guidelines, the nature of the adverse effect should be primary codes followed by T50.905A. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency services (CPT 99285) provided to the enrollee on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care services provided on July 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe subsequent nursing facility care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care services provided on July 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult diapers.
You asked the Plan to pre-approve incontinence supplies. You say that your medication makes it so you cannot
control your bladder. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve adult diapers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefixed partial denture sectioning (D9120).You asked the Planto pre-approvethe dental services. You say that this is medically necessary.The Plandenied your request. The Plansaysfixed partial denture sectioning is not a covered code under the benefit under any circumstances.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvefixed partial denture sectioning (D9120)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe medical eye exam (92004) and scanning computerized ophthalmic diagnostic imaging (92134) provided on September 1, 2020, by an out-of-network (OON) provider.You asked the Plan to waive the cost share forthe medical eye exam and scanning computerized ophthalmic diagnostic imaging. You say that you were not aware the provider was OON.The Plan denied your request. The Plan says the cost share processed correctly and no reimbursement is due.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1300 deductible for physician services rendered OON. The item or service you asked the Plan to waive the cost share for falls within the benefit category physician services rendered OON. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1300 deductible for physician services rendered OON. This cost sharing is a contractual obligation that had not been met at the time the medical eye exam and scanning computerized ophthalmic diagnostic imaging was received on September 1, 2020.Therefore, we decided that the Plan does not have to waive the cost share forthe medical eye exam (92004) and scanning computerized ophthalmic diagnostic imaging (92134) provided on September 1, 2020, by an out-of-network (OON) providerv
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not covered by Medicare for this medical condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 the monitor. Our reviewer says that the
requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided there is no documentation that the enrollee has been using insulin
multiple times (3 or more) a day. She is on once daily insulin injections. There is no documentation that the
treatment requires frequent adjustment on the basis of testing results.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D3431 and D3433).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D3431 and D3433).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on January 7, 2020.
You asked the Plan to pay for the hearing aids. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not from a covered provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when provided by a plan-approved vendor.
The hearing aids were not provided by a plan-approved vendor. Based on this information, we decided that the
Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not
have to pay for hearing aids purchased on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe specialist services provided on September 3, 2020.You asked the Plan to waive the copay forthe services provided. You say that you should not have to pay a copay for your post-op visit.The Plan denied your request. The Plan says the claim was processed 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 $40 copay for each specialist visit. You have been asked to pay a $40 copay for the services provided. The services fall within the physician services 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 copay forthe specialist services provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2740) for tooth #10.You asked the Plan to pre-approvethe crown. You say that you would like this service provided.The Plan denied your request. The Plan says tooth #10 does not appear to have significant breakdown. The Plan also says that the documentation provided does not demonstrate that there is pathologic destruction to more than 50% of the incisal edge (with incisal angle involvement) and fouror more surfaces of the tooth.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. The Plan covers the crown when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the crown for tooth #10 does not meet coverage criteria. Our physician reviewer found the Plan provides for crown restorations in certain circumstances. For anterior teeth, there must be incisal edge involvement in the order of 50% along with four or more surfaces. Our reviewer found that in this case there appears to be prior distal decay and endodontic access involvement, but not to the level dictated by the plancriteria for crowns. Endodontic treatment is not an automatic criterion for placement of a crown on an anterior tooth. Our physician reviewer also found that given the presentation of this case, there is insufficient tooth damage to meet Plan criteria forthe requested procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown (D2740) for tooth #10.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forradiation therapy visits provided from July 1, 2020, to July 31, 2020.You asked the Plan to waive thecopayments forradiation therapy. You say that you think it is unreasonable to pay this amount for each visit.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct. The Plan also says that they have reduced your cost-sharing from $150 copayment per visit to $35 copayment per visit.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 $35 copayment for each radiation therapy visit. There were 19 visits, resulting in a total copayment amount of $665.You have been asked to pay $35 copayment for radiation therapy. Radiation therapy falls withinthe Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments forradiation therapy visits provided from July 1, 2020, to July 31, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMRI of abdomen with and without contrast.You asked the Plan to pre-approvethe MRI. You say that you would like reconsideration because a follow up is recommended to ensure the stability of the lesion.The Plan denied your request. The Plan says records did not show that the member is a high-risk patient, or that the member has a known malignancy, alcoholism or underlying chronic liver condition.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that repeat MRI at the 3-month interval is not medically reasonable and necessary. Our physician reviewer found prior imaging documents no radiographic evidence of liver disease other than fatty changes,documented elevated BMI and hypertriglyceridemia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMRI of abdomen with and without contrast.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveplacement of a CardioMEMs heart failure monitor.You asked the Planto pre-approvethe CardioMEMs procedure. You say that this is necessary to help the enrollee control their heart failure symptoms.The Plandenied your request. The Plansaysthere is not sufficient evidence of the clinical benefit of this procedure.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 the CardioMEMs procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physicianreviewer found therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CardioMEMs procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveplacement of a CardioMEMs heart failure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is not able to go home, and there is not a nursing facility able to take him at this time.The Plan denied your request. The Plan says the criteria for IRF care are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for osteomyelitis and peripheral vascular disease.He has a right below the knee amputation. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.