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

We decided that the Plan does not have to pay for the subsequent hospital care rendered on October 21, 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 procedure code 99232 is not separately payable.
The Plan must follow Medicare rules. The rules say that Medicare pays for only one hospital visit per day for the same patient. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99232 under claim number x. This code was also billed and paid for by the Plan under claim number x for the same date of service. The services on the claim at issue were billed by the same provider group for the same date of service and cannot be separately paid. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waivethe deductible charges for the out-of-network lab services you received on October 2, 2019.You asked the Plan to waivethe deductible. You say that you did not know that you would have to pay this bill.The Plan denied your request. The Plan says the deductible was not met.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 $1,500 deductible for out-of-network medical services. The services in question were provided to you by an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible for out-of-network medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received on October 2, 2019.Therefore, we decided that the Plan does not have to waivethe deductible charges for the out-of-network lab services you received on October 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 5, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a corrected claim with a valid HIPPS (Health Insurance Prospective Payment System) code, a valid 18 digit alphanumeric Treatment Authorization Code, correct type of bill, and a valid 5-digit CBSA (Computer Based Statistical Area) code are needed to reprocess and pay the claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted with an invalid Type of Bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity additions; Symes Type Post Opening Socket, Lacer Molded to patient, and upper extremity additions; heavy duty control cable, Teflon/Equal cable lining, and excursion amplifier.You asked the Plan to pre-approve lower extremity additions; SymesType Post Opening Socket (L5634), Lacer Molded to patient (L2330), and upper extremity additions; heavy duty control cable (L6660), Teflon/Equal cable lining (L6665), and excursion amplifier (L6641).You say that the enrollee needs the prosthesis extremity additions.The Plan denied your request. The Plan says the enrollee does not meet criteria for the lower extremity additions and the upper extremity additions are not appropriate.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.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 lower extremity additions; Symes Type Post Opening Socket (L5634), and Lacer Molded to patient (L2330). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the Lacer L2330 is not medically necessary as the base orthosis is not medically necessary. This request applies to an ankle foot orthotic and is not appropriate for the enrollee's conditionor transtibial amputation per the LCD Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686). The addition to lower extremity, Symes type L5634 is not medically necessary per the LCDLower Limb Prostheses(L33787)as the patient does not have a Symes amputation therefore the L5634 is not appropriate forthe enrollee'scondition.We looked at this physician's review, the file, and Medicare rules. We find that CPT codes L6660, L6665,andL6641 are not supported in the medical record. Specifically,these are upper extremity additions and the enrollee has a lower extremity prosthesis. Based on this information, we decided that Medicare rules for coverage of lower extremity additions; Symes Type Post Opening Socket (L5634), Lacer Molded to patient (L2330), and upper extremity additions; heavy duty control cable (L6660), Teflon/Equal cable lining (L6665), and excursion amplifier (L6641)have not been met.Therefore, we decided that the Plan does not have to pre-approve lower extremity additions; Symes Type Post Opening Socket, Lacer Molded to patient, and upper extremity additions; heavy duty control cable, Teflon/Equal cable lining, and excursion amplifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approv replacement of an oral prosthesis (mouth guard).You asked the Plan to pre-approvereplacement of mouth guard. You say that your previous mouth guard that was approved broke in your mouth and caused your mouth injury. You have a lot of pain in your jaw and do not want the result to end up in getting surgery.The Plan denied your request. The Plan says this item is not covered under the plan benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan replacement of mouth guard, involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Based on this information, we decided that Medicare rules for coverage of replacement of mouth guard have not been met.Therefore, we decided that the Plan does not have to pre-approvereplacement of an oral prosthesis (mouth guard).
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the EEG. We decided that the Plan does not have to waive the coinsurance for the EEG.
You asked the Plan to waive the coinsurance for the EEG. You say that you are appealing this claim. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the coinsurance for the EEG.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the coinsurance amount that was applied is incorrect. The allowed amount for the EEG is $3,591.84. (Total charges of $3,908.68 - the Plan's disallowed amount of $316.84 = allowed amount of $3,591.84). This means the coinsurance amount is $718.37. ($3,591.84 x 20% = $718.37).
The Plan says that you must pay a coinsurance amount of $721.54 for the EEG. Based on the plan contract, however, you cannot be asked to pay more than a $718.37 for the EEG. Therefore, we decided that the Plan has to reduce the coinsurance for the EEG from $721.54 to $718.37.
We also decided that the Plan does not have to waive the coinsurance for the EEG.
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 the EEG. ($3,591.84 x 20% = $718.37). Therefore, we decided that the Plan does not have to waive the coinsurance for the EEG.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on November 5, 2019.
You asked the Plan to reimburse you for the dental service. You say that you see the dentist once per year for periodontal maintenance. You say that periodontal maintenance is a dental cleaning and therefore should be covered. The Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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, periodontal maintenance is not among those covered under this benefit. The Evidence of Coverage clearly states that cleanings (prophylaxis) are covered. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvethe requested bed. You say that the bed will help you maintain your independent lifestyle.The Plan denied your request. The Plan says the height adjustment feature is a convenience feature.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on November 26, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that you were not told in advance of the 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 $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls 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 copayment forthe laboratory work provided on November 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on October 13, 2018.
You asked the Plan to pay for the home health services. You say that you would like reconsideration because this claim was submitted timely to the medical group. The Plan denied your request. The Plan says non-par providers are required to submit claims within 365 calendar days from the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the home health services was not filed until December 2, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for home health services provided on October 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses providedon October 26, 2019.You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says you do not have out-of-network benefits under your Plan.Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at thefile and the Plan's rules. The provider at issue in this appeal is not a Plan vision provider. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on October 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core build up, including any pins when required (D2950) and a porcelain crown fused to high noble metal (D2750).
You asked the Plan to pre-approve these services. You say that the services are dentally necessary as this tooth has crack lines present. The Plan denied your request. The Plan says there is no need for replacement of the existing crown. An open margin without documented presence of active recurrent decay does not meet criteria for crown replacement. Esthetics is also not considered a need for replacement of the existing crown. In addition, the requested filling for a crown with post for the right maxillary second premolar has been denied because this service is not a covered benefit under the Plan contract.
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 these services 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 if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the enrollee does not meet criteria for coverage of the dental crown. Our physician reviewer found that the crown already in place on tooth #4 appears adequate and functional. There is no indication of recurrent caries or defects which would necessitate replacement.
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 these services have not been met. Additionally, a core build-up is not a covered procedure under this plan contract. Therefore, we decided that the Plan does not have to pre-approve a core build up, including any pins when required (D2950) and a porcelain crown fused to high noble metal (D2750).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on June 7, 2019.You asked the Plan to pay forthe genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. ThePlan says the services rendered are not a covered benefit.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, the genetictesting, 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 forthe genetic testing provided on June 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic services (98941) provided on April 24, 2019 through May 20, 2019.You asked the Plan to waive the deductible for the chiropractic services. You say that you would like reconsideration because your deductible was met by the end of May 2019.The Plan denied your request. The Plan says until you have paid the deductible amount, you must pay the full cost of your covered services.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 $500 deductible before the Plan will cover their share.You have been asked to pay the deductible amount for the chiropractic services.  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.Please note, the Plan has confirmed that the dates of service after May 2019 are being handled separately.Therefore, we decided that the Plan does not have to waive the deductible for chiropractic services (98941) provided on April 24, 2019 through May 20, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia (J0897).You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation, coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound study provided on December 9, 2019.
You asked the Plan to waive the copayment for an ultrasound study. 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 a $100 copayment for basic radiological services provided in an outpatient hospital facility. You have been asked to pay $40, which is less than the $100 copayment for an ultrasound study. An ultrasound study falls 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 copayment for an ultrasound study provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extractions teeth 8, 9, 10, 22 (D7210).
You asked the Plan to pre-approve the surgical extractions. You say that you were advised by the dental surgeon that you needed 6 extractions. Your partial dentures are ready but you need the extractions first and it costs $150 per extraction and $600 in total. The Plan denied your request. The Plan says this request exceeds the benefit limit of 2 extractions (non-surgical or surgical) a year.
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 contract allows for 2 non-surgical or surgical extractions a year. The plan has already approved surgical extractions for teeth 7 and 23. Therefore, this benefit has been exhausted. 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 surgical extractions teeth 8, 9, 10, 22 (D7210).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approve additional transportation. You say that you do not have anyone to take you to dialysis.The Plan denied your request. The Plan says your benefit only allows 30 trips for this service.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on July 20, 2019.You asked thePlan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99152 is not supported.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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 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 pay forthe moderate sedation services rendered on July 20, 2019.