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

We decided that the Plan does not have to waive the copayment for the surgical nail removal service (11750) provided on August 20, 2020.
You asked the Plan to waive the copayment for the nail removal service. You say that the procedure was so minor that you thought it would be covered by your exam fee. The Plan denied your request. The Plan says this service is a surgical procedure, and outpatient surgery services are subject to a $200 copayment.
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 $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for the nail removal service. The nail removal service is classified as a surgical procedure and falls within the outpatient surgery 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 surgical nail removal service (11750) provided on August 20, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on August 13, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you believe that these services should be covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered benefit. The Plan also says that the payment for the first intraoral periapical x-ray processed correctly because you saw an OON provider.
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, problem focused limited oral evaluation is not among those covered under this benefit. The contract also states that if you receive services from an OON provider, you may pay more. You are responsible for the difference between the billed amount and allowed amount for the first intraoral periapical x-ray. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on August 13, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral formula, nutritionally complete with intact nutrients (B4150) enteral feeding supply kit (B4034).

You asked the Plan to pay for the enteral supplies. You say that you require reimbursement for unpaid charges indicated on the claims that include necessary supplies and service charges applicable to the medication being administered to the enrollee. The Plan denied your request. The Plan says the records do not support the billed service.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for enteral formula, nutritionally complete with intact nutrients (B4150) enteral feeding supply kit (B4034).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the specialist office visits (99212, 11900) and the Triamcinolone Acetonide injection (J3301) provided September 28, 2020, and October 13, 2020.
You asked the Plan to waive the cost-share for the specialist office visits and the injection. You say that your provider told you that you would not be charged for the services. The Plan denied your request. The Plan says the cost-sharing was 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 $45 copayment for an office visit with a specialty physician and a 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a total of $89.31 for two office visits with a specialist and the Triamcinolone Acetonide injection. The specialist office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category. The injection falls within the Medicare Part B prescription drugs 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 cost-share for the specialist office visits (99212, 11900) and the Triamcinolone Acetonide injection (J3301) provided September 28, 2020, and October 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic exercises to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110x24)
You asked the Plan to pre-approve the therapeutic exercises. You say that this new therapist, which you have seen only 2 times is very good and you have improved immeasurably with her. The Plan denied your request. The Plan says the records do not support that more physical therapy is medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 therapeutic exercises. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that her functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The recent therapy notes do not reveal objective measures of functional improvement from prior therapy or objective deficits that require ongoing supervised skilled therapy. There has been instruction in a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic exercises to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110x24)
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the pelvis.

You asked the Plan to pre-approve an MRI of the pelvis. You say that the requested MRI of the pelvis is medically necessary. The Plan denied your request. The Plan says that the requested MRI of the pelvis is not medically necessary.

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 an MRI of the pelvis. Our reviewer says that the requested MRI of the pelvis is medically necessary. Our physician reviewer found the enrollee is with elevated PSA of 8.5 ng/mL that was evaluated with ultrasound guided biopsy with benign histology. PSA has increased up to 12.8 ng/mL on 1/2021 and request is for coverage of MRI of the pelvis/prostate.

The requested MRI of the pelvis is medically reasonable and necessary for the enrollee in this case. According to the Joint Consensus Statement of the American Urological Association (AUA) and Society of Abdominal Radiology (SAR) "when high-quality prostate MRI is available, it should be strongly considered in any patient with a prior negative biopsy who has persistent clinical suspicion for prostate cancer and who is undergoing a repeat biopsy."

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the pelvis have been met. Therefore, we decided that the Plan has to pre-approve an MRI of the pelvis.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4221 and A4222) provided on March 28, 2020, through April 6, 2020.

You asked the Plan to pay for the infusion supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are inclusive under services approved and paid to the attending oncologist.

The Plan must follow Medicare rules. Medicare rules say that Medicare's payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. 

We find that CPT codes A4221 and A4222 are not supported in the record. Specifically, payment for these supplies is included in the administration payment made to the physician or facility. Based on this information, we decided that Medicare rules for coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay for infusion supplies (A4221 and A4222) provided on March 28, 2020, through April 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric office visit (90834) and evaluation (90791)
provided on November 17, 2020, by an OON provider.
You asked the Plan to pay for the psychiatric office visit and evaluation. You say that you were told by
customer service that this provider was in-network. The Plan denied your request. The Plan says the provider of
these services is not in network, and there is no record of this provider's name being provided by customer
service.
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 had network providers
available who could have provided 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 for the psychiatric office visit (90834) and evaluation
(90791) provided on November 17, 2020, by an OON provider.
Your complaint about possible misinformation provided by customer service is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve lumbar spine magnetic resonance imaging.
You asked the Plan to pre-approve magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without contrast material (72148). You say that the enrollee has had bilateral lower extremity discomfort for years and needs a lumbar MRI. The Plan denied your request. The Plan says that the enrollee had a recent MRI lumbar spine so a requested repeat of MRI lumbar spine is not medically necessary.
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 magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without contrast material (72148). Our reviewer says that the MRI is medically necessary. Our physician reviewer found in this case, the enrollee has evidence of neuropathy and root compromise. Therefore, the MRI is medically necessary and reasonable to diagnose pathology. Therefore, coverage is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without contrast material (72148) have been met. Therefore, we decided that the Plan has to pre-approve lumbar spine magnetic resonance imaging.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Negative pressure wound therapy electrical pump (E2402) provided between July 8, 2020 and August 3, 2020.

You asked the Plan to waive the coinsurance for the Negative pressure wound therapy electrical pump. You say that the provider did not inform you of the cost of the service. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for each Medicare covered DME item. 

You have been asked to pay a total of $796.50 ($3,982.50 total allowed amount x 20% coinsurance) for the Negative pressure wound therapy electrical pump. This service falls within the Durable medical equipment (DME) and related 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 coinsurance for the Negative pressure wound therapy electrical pump (E2402) provided between July 8, 2020 and August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) provided on August 27, 2020.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your dental policy.

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 item provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forDME and related supplies provided on August 13, 2020.You asked the Plan to waive the coinsurance forDME and related supplies. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 20% coinsurance for DME and related supplies. You received DME and related supplies on August 13, 2020. The total allowed amount is $121.46 and 20% of that is $24.29. You have been asked to pay the total coinsurance amount of $24.29 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance forDME and related supplies provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided by an out of network (OON) provider.
You asked the Plan to pay for the outpatient office visit. You say that the out-of-network services should be covered. The Plan denied your request. The Plan says services provided by an out-of-network provider either require per-approval or be provided on an urgent or emergent basis.
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 had network providers available who could have provided 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 for the outpatient office visit provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that insurance would cover the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 20% coinsurance for DME and related supplies.

You received DME and related supplies. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see chart provided.

The total amount you owe is: $34.78.

You have been asked to pay the total coinsurance amount of $34.78 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee is receiving appropriate care in the acute care hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.