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

We decided that the Plan does not have to pay for a drug test provided on December 4, 2019.
You asked the Plan to pay for the drug test. 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 drug test. 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 drug test provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical placement of implant body: endosteal implant provided on December 19, 2019.You asked the Plan to pay forthe endosteal implant. You say that the only thing your dentist could do was give you an implant to replace the tooth. You also say that this tooth is necessary to be able to bite into food.The Plan denied your request. The Plan says this service 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 pay forthe surgical placement of implant body: endosteal implant provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 31, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you and the insurance copayment should not have to pay for something you did not get. You say you did not receive any anesthesia. 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 $45 copayment for each Medicare-covered visit with an in-network specialist. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $45 copayment for the specialist office visit.
You have been asked to pay a $28.54 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a chronic pain management consultation.
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 specialist office visit provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe catheter and lubricant provided on January 3, 2020.You asked the Plan to waive the coinsurance forthe catheter and lubricant. You say that you have never had a copayment for catheters. You say that you were not aware of the changes in cost.The Plan denied your request. The Plan says the coinsurance 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 15% coinsurance for prosthetic devices and medical supplies.You have been asked to pay a total of $33.85 for the catheter and lubricant. Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityJanuary 3, 2020Catheter$224.115%$33.61January 3, 2020Lubricant$1.6215%$0.24TOTAL:$33.85The catheter and lubricant fall within the "Prosthetic devices 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 forthe catheter and lubricant provided on January 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on September 24, 2019.You asked the Plan to payforthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 99212 was not billed correctly.The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis.We looked at the file and Medicare rules. The file shows that CPT code 99212 was billed with one or more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosiscodes when a more specific, in this case; bilateral code is available.Therefore, we decided that the Plan does not have to pay forthe physician services provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve provisional splinting.
You asked the Plan to pre-approve provisional splinting. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 provisional splinting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the stair lift provided to the enrollee on August 13, 2019.
You asked the Plan to pay for the stair lift. You say that using stairs is almost impossible for the enrollee. The
Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pay for the stair lift provided to the enrollee on August 13,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on December 19, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for assisted living services. You say that these services were provided in an assisted
living facility. You say that you would like payment for these services. The Plan denied your request. The Plan
says no prior authorization was obtained. The Plan says that the referring facility is out-of-network.
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 for assisted living services provided on December 19,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says these services are available in-network
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran outpatient surgical procedure provided on November 20, 2019.You asked the Planto waive the coinsurance foran outpatient surgical procedure. 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 saya 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 4% coinsurance for each outpatient hospital visit.You received an outpatient surgical procedure on November 20, 2019. The allowed amount is $371.82 and 4% of that is $14.88.  You have been asked to pay the total coinsurance amount of $14.88 for an outpatient surgical procedure. An outpatient surgical procedure falls within the outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers 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 foran outpatient surgical procedure provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home use.
You asked the Plan to pre-approve the drugs or medicaments. The Plan denied your request. The Plan says this service is not covered by the enrollee's plan.
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 drugs or medicaments dispensed in the office for home use.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome infusion therapy (HCPCS S9328) provided to the enrollee from December 17, 2019 to December 24, 2019.You asked the Planto pay forthe therapy. You say that this should be paid for.The Plandenied your request. The Plansaysthis is an invalid procedure code for this service.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 HCPCS code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem."We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met.Therefore, we decided that the Plandoes not haveto pay forhome infusion therapy (HCPCS S9328) provided to the enrollee from December 17, 2019 to December 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments. You asked the Plan to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments. The Plan denied your request. The Plan says you do not meet the criteria
established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020. The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical
conditions under the Plan's debit card allowance benefit. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous process stabilization device (Superion IDS).
You asked the Plan to pre-approve Superion IDS procedure. You say that this procedure is medically necessary for the enrollee, and the enrollee meets criteria. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because these is a lack of evidence that this procedure is as safe and effective as the gold standard of decompression.
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 Superion IDS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis and experiences neurogenic claudication. She has been treated with non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and epidural steroid injections. There is little published literature comparing outcomes of the Superion device to standard decompression surgery. Without the support of medical literature, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion IDS procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous process stabilization device (Superion IDS).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 2, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spine x-ray provided on August 2, 2019.
You asked the Plan to waive the copayment for the spine x-ray. You say that the service was performed at the advanced imaging center. You say that the copayment should be $40. 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 $90 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $90 copayment for the spine x-ray. The spine x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the x-ray was billed by the hospital. 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 spine x-ray provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 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 enrollee has chronic low back pain with radiation to her legs. She has had two sessions of physical therapy and is taking Mobic for pain. She has not had any imaging. She has both sciatica and axial pain. The requested MBBs do not meet the criteria for coverage and are not reasonable or medically necessary at this time. 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 diagnostic medial branch blocks (MBBs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 13, 2019.You asked the Plan to pay forthe orthoses. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two fixed prosthodontic procedures (D6999).
You asked the Plan to pre-approve the fixed prosthodontic procedures. You say that because of your extreme bone loss your dentures will not stay on. You also say that your overall health is bad because of your teeth. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 the two fixed prosthodontic procedures (D6999).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional services performed by a qualified physical therapist in the home health, each 15 minutes (G0151).You asked the Plan to pre-approve the additional services performed by a qualified physical therapist. The Plan denied your request. The Plan says the enrollee has achieved most of the therapy goals and have assistance at home with aides for additional support. The Plan also says that the Medicare coverage criteria were not met for additional physical therapy visits.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 additional services performed by a qualified physical therapist. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee's functional level does not require ongoing skilled physical therapy. Our reviewer found that the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. Our physician reviewer also found that 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 orto prevent or slow further deterioration.