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

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays provided by an OON provider on November 20, 2019.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays. You say that you have been seeing this same dentist who knows your history and you trust for years. The Plan denied your request. The Plan says services done by an out-of-network dentist are not covered. The Plan also says that the dentist that rendered these services is not part of the Plan's network.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays provided by an OON provider on November 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 21, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the hospital didn't do anything to bring your blood pressure down. You say that you received no medical care. 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 $75 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency Care" benefit category. The records show that you were seen in the ER. 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 ER visit provided on January 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing and occupational therapy home health visits.
You asked the Plan to pre-approve additional home health visits. 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 medically necessary.
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 looked at the file, and Medicare rules. Review of the file shows that medical records were requested by your providers with no response. Therefore, medical records were not provided to support that the requested additional home health visits are medically necessary. Based on this information, we decided that Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing and occupational therapy home health visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on January 3, 2020.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you paid less for the same procedure last year when you had Original Medicare. 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 $350 copayment for each Medicare-covered in-network ambulatory surgical center visit. You have been asked to pay a $350 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient 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 copayment for the upper GI endoscopy provided on January 3, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the orthosis. 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 rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 25, 2019. You asked the Plan to pay for the orthosis. 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 rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided to you from December 5, 2019, to December 18, 2019.
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided to you from December 5, 2019, to December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on January 7, 2002.
You asked the Plan to waive the copayment for an X-ray. You say that the X-ray should be considered as part of a follow-up to a surgical procedure. 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 $5 copayment for basic radiology. You have been asked to pay a $5 copayment for an X-ray. An X-ray 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 X-ray provided on January 7, 2002.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy provided on January 3, 2020. You asked the Plan to waive the copayment forthe endoscopy. You say that this should have been treated as a screening. You say that this is not a justified copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must discloseto 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 $75 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.You have been asked to pay a $75 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a diagnostic procedure. 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 endoscopy provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on January 22, 2020
and January 23, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were not self-administered,
but were given to you while you were in the hospital. The Plan denied your request. The Plan says these drugs
are self-administered drugs. The Plan also says that these drugs are not Part B covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided on January 22, 2020 and January 23, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit injection, 18 units.
You asked the Plan to pre-approve Procrit injection. You say that the requested Procrit is needed to help the enrollee function. You say that it significantly improves his quality of life when he gets the injections. The Plan denied your request. The Plan says the criteria for coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Procrit injection. Our reviewer says that the requested Procrit injections are not medically necessary. Our physician reviewer found based on the documentation provided the requested Procrit injections are not medically necessary. The reviewer also found that the provided documentation does not support that the Procrit injections would be safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit injection, 18 units.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics, and power seat elevation system.
You asked the Plan to pre-approve power wheelchair upgraded electronics, and power seat elevation system. You say that you need a Group 3 power wheelchair, accessories, upgraded electronics, and power seat
elevation system. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare and it is not medically necessary to control the three approved power options through the joystick.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Power seat elevation features are not covered by Medicare or the Plan. Documentation shows that you have normal range of motion and strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for you to be able to control the power options using their own switches which are included in the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve power wheelchair upgraded electronics, and power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on December 11, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the 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 99152 and 99153 are not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status; therefore, code 99152 cannot be verified. Code 99153 is not covered because the required primary service code (code 99152) was not covered. Also, the documentation submitted and the claim form indicate that this procedure was performed in a facility place of 22 (On Campus - Outpatient Hospital). Payment for this service is included in the payment to the facility and not separately reimbursable for this provider in this place of service. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 17, 2019 through November 19, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 17, 2019 through November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on March 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit services provided on March 23, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral alprazolam, ticagrelor, diphenhydramine, and morphine solution provided during an outpatient hospital stay on January 16, 2020. You asked the Plan to reimburse you for the self-administered drugs. You say that you did not receive any "self-administered drugs" on the occasion of your cardiac catheterization. You also say that you should have received a bill. The Plan denied your request. The Plan says the drugs that you received in the hospital are considered "self-administered", or drugs that you would normally take on your own. The Plan also says self-administered drugs are not covered under Part B Medicare. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to reimburse you for the oral alprazolam, ticagrelor, diphenhydramine, and morphine solution provided during an outpatient hospital stay on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on January 6, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says CPT 71045 is denied as inclusive to CPT 32557.
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 71045 is "Radiologic examination, chest single view." We find that CPT code 71045 is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure - CPT 32557 - that has been billed on this claim. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions for teeth #6-12.
You asked the Plan to pre-approve the dental extractions. You say that you had a car accident 40 years ago where your jaw came crashing down on the steering wheel and caused hairline fractures on your teeth. You say that, at the time, your dentist did not recommend any treatment because he said that your teeth may or may not bother you. You say that now when you bite down, you hit a nerve and your teeth bother you. You say that you are also getting abscesses in your mouth which is causing your system to be poisoned. You say that you have pulled three of your own teeth in the past after the abscesses have drained, which caused you to have to go to the emergency room. You say that you have had a stroke and cannot afford another. You say that you cannot afford to pay for the extractions. The Plan denied your request. The Plan says the enrollee's benefit for dental extraction services has been exhausted for the 2020 plan 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for dental extractions is limited to 2 per calendar year. The records show that the Plan approved 2 dental extractions on January 22, 2020. These two approved extractions would exhaust the benefit for dental extractions in the 2020 calendar year. Therefore, we decided that the Plan does not have to pre-approve dental extractions for teeth #6-12.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will be best served at an LTACH. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 as LTACHs and acute care hospitals 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 acute care hospital until such time as no acute services are required, 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 long term acute care hospital (LTACH) services.