Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Periodontal Maintenance (D4910) provided on December 4, 2019 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you were advised that the plan would for your deep cleaning, but you were never told about the $100 deductible.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.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.For code D4910, the provider billed the plan $149.00. The allowed amount for the service is $114.00, the $100.00 deductible was applied to the service, making the allowed amount $14.00, and the plan paid $7.00. You are responsible for your 50% cost share, in addition to plan's $100.00 deductible, $107.00 ($114 -$7). You are responsible for 50% of the allowed amount for the service, in addition to the $100.00 that applied to the claim, $107.00 ($114 -$7). The $107.00 which was assessed as your cost-share is correct. Your EOC states, there is a $100 Deductible (doesn't apply to exams, bitewings, all x-ray services, cleanings, or fluoride). You pay 50% for Periodontal maintenance -Two (2) procedures per plan year.Therefore, we decided that the Plan does not have to pay forPeriodontal Maintenance (D4910) provided on December 4, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 4, 2020 through January 6, 2020. You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe you should not be responsible for both copayments for each of the inpatient stays because the facility was unable to perform your surgery. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on January 4, 2020 and discharged on January 6, 2020. You were asked to pay a $325 copayment per day from January 4, 2020 through January 5, 2020, days 1-2 of your inpatient hospital care. You were discharged on January 6, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-6., per admission. 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 hospital care from January 4, 2020 through January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic (root canal) therapy (D3320) provided February 11, 2020.
You asked the Plan to pay for the dental services. You say that you did not know that the provider is opted out of Medicare. You paid the bill at the time of service but would the root canal to be covered. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for endodontic (root canal) therapy (D3320) provided February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says medical conditions have remained stable.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 you were medically stable, with no evidence of a need for supervision by a PMR physician. There was no need for acute rehab nursing care. You are functionally at a minimum assist level, with no acuity. Therefore, there is no need for the IRF level of therapy. You may benefit from further therapy, but you do not need an intensive therapy program. This admission is not medically necessary based on your current functional status and medical stability.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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ALS emergency ambulance (A0427) and ground mileage (A0425) provided December 29, 2019. You asked the Plan to pay for the ambulance service. You say that please see the attached report showing this was an ambulance transport, an emergency service, therefore no pre-certification or authorization is required. The Plan denied your request. The Plan says non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The documentation does not support that other means of transport were contraindicated. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport was medically reasonable and 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 the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ALS emergency ambulance (A0427) and ground mileage (A0425) provided December 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SPRINT PNS system (peripheral nerve stimulator) for the enrollee.You asked the Plan to pre-approve the system. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of this health problem.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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found the effectiveness of the SPRINT PNS system for osteoarthritis of the shoulder has not been established in the peer reviewed literature and remains experimental/ investigational at this time. Therefore, the request is considered not medically reasonable or 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 the system have not been met.Therefore, we decided that the Plan does not have to pre-approve SPRINT PNS system (peripheral nerve stimulator) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ultrasound and the MRI provided on
April 22, 2019 and June 26, 2019.
You asked the Plan to waive the copayments for the ultrasound and the MRI. You say that you were told you
would not have copayments. The Plan denied your request. The Plan says you have been charged the correct
cost sharing 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 a $25
copayment for Medicare-covered ultrasound at a freestanding provider and a $75 copayment for Medicarecovered
MRI, MRA, and angiogram at a freestanding provider.
You have been asked to pay a $25 copayment for the ultrasound and a $75 copayment for the MRI. The
ultrasound and the MRI fall within the "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 for the ultrasound the MRI
provided on April 22, 2019 and June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 20, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 laboratory services. 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 laboratory services provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80053, 84439, 84481, 82306, 84681, 84144, 83735, 83525, 80061, 84550, 82670, 83001, 83002, 82533, 84403, 83970, 82610, 85025, and 84443 provided on September 17, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan saysthe services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80053, 84439, 84481, 82306, 84681, 84144, 83735, 83525, 80061, 84550, 82670, 83001, 83002, 82533, 84403, 83970, 82610, 85025, and 84443 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records signed by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 80053, 84439, 84481, 82306, 84681, 84144, 83735, 83525, 80061, 84550, 82670, 83001, 83002, 82533, 84403, 83970, 82610, 85025, and 84443 provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for maintenance of the oxygen concentrator performed on February 27, 2020. You asked the Plan to waive the coinsurance for maintenance of the oxygen concentrator. You say that you did not request this service and you should not be responsible for the cost-share. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received maintenance of the oxygen concentrator performed on February 27, 2020. You are asked to pay 20% coinsurance for the maintenance of the oxygen concentrator. 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 maintenance of the oxygen concentrator performed on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) cleaning (D1110) bitewing x-rays (D0274) intraoral - periapical first x-rays (D0220) intraoral - periapical each additional x-rays (D0230) provided January 7, 2020.
You asked the Plan to pay for the dental services. You say that the provider's office told you that they were in network and you have already paid $100. The Plan denied your request. The Plan says enrollees must receive their dental services from an in-network 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodic oral exam (D0120) cleaning (D1110) bitewing x-rays (D0274) intraoral - periapical first x-rays (D0220) intraoral - periapical each additional x-rays (D0230) provided January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there have not been many failed attempts made to see if the enrollee is able to safely breathe on their own.
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. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following a stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator. It is unclear if ventilator liberation or decannulation are expected. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 admission to a long term acute care hospital (LTACH).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs few more weeks of therapy to assist her in becoming more independent. The Plan denied your request. The Plan says the guidelines for continued SNF care have not been met because there are not noted daily skilled complex nursing or therapy needs. The Plan says that, while the enrollee may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy on an inpatient basis. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment beyond the last covered day. The enrollee does not have complex wound care, a need new enteral feedings or other SNF level need. The enrollee's functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment beyond the last covered date. It is not medically reasonable and necessary to provide ongoing skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." As a practical matter the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered day. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic care provided from January 8, 2020 to February 5, 2020.You asked the Plan to pay for the chiropractic care. You say that you were never notified that you needed to get another approval from your physician. The Plan denied your request. The Plan says chiropractic care is covered when provided by a Plan chiropractor when referred by a Plan provider.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 Plandid not pre-approve the chiropractic care.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 chiropractic care provided from January 8, 2020 to February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean advanced leg pump device (CPT E0652).You asked the Plan to pre-approvethe advanced leg pump device. You say that you are low income because you have retired and because you are unable to afford the requested device on your own.The Plan denied your request. The Plan says the enrollee only has swelling in the thigh and leg and a regular pump would be appropriate.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 advanced leg pump device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provideddo not show that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen which has remained unresponsive to all other therapies.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 advanced leg pump device have not been met.Therefore, we decided that the Plan does not have to pre-approvean advanced leg pump device (CPT E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the specialist office visit and the Part B drug provided on February 12, 2020.
You asked the Plan to reduce the cost share for the specialist office visit and Part B drug. You say that that all the services should be covered with a $10 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $50 copayment for specialist visits and 20% coinsurance for Part B drugs that are administered by a provider. You have been asked to pay a $50 copayment for the specialist office visit and $16 which is 20% of the allowed amount for the Part B drug. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drug 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 reduce the cost share for the specialist office visit and the Part B drug provided on February 12, 2020.