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

We decided that the Plan does not have to waive the cost share for the neurostimulator implantation and neurostimulator provided on September 9, 2019.
You asked the Plan to waive the cost share for the neurostimulator implantation and neurostimulator. You say that the bill is more than it should be. The Plan denied your request. The Plan says the cost share 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 $100 copayment for outpatient surgery at an outpatient hospital and 20% coinsurance for medical supplies. You have been asked to pay a $100 copayment for the neurostimulator implantation. You have also been asked to pay $3,030, which is less than the standard 20% coinsurance for the neurostimulator because you met your maximum out-of-pocket. The total amount you owe is $3,130 ($100 + $3,030 = $3,130). The neurostimulator implantation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The neurostimulator falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the neurostimulator implantation and neurostimulator provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator (E0466). You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the requested home ventilator is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator (E0466). Our reviewer says that the requested home ventilator is not medically necessary. Our physician reviewer found the enrollee does have severe chronic obstructive pulmonary disease (COPD) with hypercarbic respiratory failure, although specific blood gas data are not provided in the record. The enrollee has been on BiPAP at home, but no compliance data are provided. This admission appears to have been caused by a COPD exacerbation, and does not meet Medicare criteria for BiPAP failure. BiPAP failure is demonstrated by persistent hypoxemia or worsening overnight hypercarbia, when in a stable state, while on BiPAP with appropriate oxygen supplementation. The physician's note indicates the enrollee would benefit from the AVAPS-AE mode of ventilation, and this can be provided with certain BiPAP devices. Medicare does not cover home ventilators when used as BiPAP. This enrollee should be sent home with BiPAP in AVAPS-AE mode. A home ventilator is not medically 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 a home ventilator (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care services (CPT 99232) provided to the enrollee on August 20, 2019 and August 21, 2019.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 the provider cannot bill this code twice on the same day.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 99232 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is no evidence that two separate and distinct services were provided on the dates of service in question. Therefore, the billing of CPT 99232 twice on this date of service is not supported.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 services have not been met.Therefore, we decided that the Plan does not have to pay for subsequent hospital care services (CPT 99232) provided to the enrollee on August 20, 2019 and August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower. You asked the Plan to pre-approve a walk-in shower. The Plan denied your request. The Plan says that hygienic equipment is not covered as it is not primarily medical in nature.
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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided on November 9, 2019.
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that you were not advised the cost would be increasing. You say that you should not be liable. 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 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other in-network Medicare Part B drugs. You have been asked to pay $1,840.94, which is 20% of the allowed amount for the leuprolide acetate suspension. The allowed amount is $9,204.72 (20% x $9,204.72 = $1,840.94). The leuprolide acetate suspension falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided on November 9, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide a continuous glucose monitor (CGM). You asked the Plan to provide the CGM. You say that the CGM is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 provide the CGM. Our reviewer says that the CGM is medically necessary. Our physician reviewer found the enrollee has a slow healing wound and is concerned about low blood glucose affecting wound healing. The enrollee has a fear of needles and will not use a traditional glucometer. The records show that the requested CGM is medically reasonable. 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 CGM have been met. Therefore, we decided that the Plan has to provide a continuous glucose monitor (CGM). If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient dental surgery procedure coded as 99202 and 41899, provided October 10, 2019.You asked the Plan to pay forthe outpatient dental procedure. You say that you fell and broke your tooth. This was an accident and should be covered by your medical.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. The health plan contract on page 89 says that dental care such as cleanings, fillings or dentures or treatment or removal (extraction) or replacement of teeth is not covered under any condition. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services arenot among those covered under this benefit.Therefore, we decided that the Plan does not have to pay foroutpatient dental surgery procedure coded as 99202 and 41899, provided October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick 50mg/ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is a benefit exclusion.
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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from October 28, 2019 to November 3, 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 claim was not billed correctly. The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were not billed with the appropriate TOB code. 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 for the home health services rendered to the enrollee from October 28, 2019 to November 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystourethroscopy provided on December 4, 2019.
You asked the Plan to reduce the copayment for the cystourethroscopy. You say that your doctor recommended you have the procedure at this hospital but did not inform you of the large copayment. You say you were told if you had gone to a different location, you would have had a $50 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 $400 copayment for an outpatient hospital facility. You have been asked to pay a $400 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient hospital services" 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 copayment for the cystourethroscopy provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing(D4341) for all 4 quadrants and a filling (D2335) for tooth # 9.You asked the Plan to pre-approve the dental services. You say that you did not receive the services previously. You say that you had bad service and got mistreated by your previous dental provider. You say that they only filled 1 tooth and busted your lip when doing it.The Plan denied your request. The Plan says the quarterly maximum of $400 has been exhausted.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 and the requested dental services are listed as covered, the $400 quarterly maximum has been exhausted. The record shows that the Plan paid $349 towards the lower partial denture that were approved on January 27, 2020 and $51 towards the dental services that you received on January 2, 2020.Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants and a filling (D2335) for tooth # 9.MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern. MAXIMUS Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided from June 5, 2019 through June 7, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that you were informed two visits would be combined. You say that the balance would be $325.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 $325 copayment for surgical services at an in-network outpatient hospital facility.You have been asked to pay a $325 copayment for the endoscopy. The 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 forthe endoscopy provided from June 5, 2019 through June 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for advanced radiology services provided from November 22, 2019 to December 6, 2019.You asked the Plan to waive the copayments for advanced radiology services. You say that you request that the copayments be lowered to $100.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 $175 copayment for advanced radiology services.You received advanced radiology services from November 22, 2019 to December 6, 2019 for a total of 3 visits. Therefore, you are responsible to pay a $175 copayment per each advanced radiology service. The total amount you owe is: $175 (copayment) x 3 (advanced radiology) = $525.You have been asked to pay the total copayment amount of $525 for advanced radiology services. Advanced radiology services 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 advanced radiology services provided from November 22, 2019 to December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided by IntelligeneCG on August 23, 2019.You asked the Plan to pay for screening tests. You say that the ordering provider determined that these tests were medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a covered benefit for the diagnoses listed and were performed for screening purposes.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 tests at issue in this appeal, screening tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay for genetic screening testing provided by IntelligeneCG on August 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PRALUENT Pen.You asked the Plan to pre-approve the PRALUENT. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says PRALUENT is patient self-administered and therefore not covered by Medicare Part B.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 pre-approve a PRALUENT Pen.Benefits for the PRALUENT 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergency ambulance transportation provided on June 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe ambulance transportation. You say that you feel the service should be covered because they waited until it was too late to recover the full amount.The Plandenied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.Medicarerules 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 forthe non-emergency ambulance transportation provided on June 4, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the cost share for the laboratory services provided on August 22, 2019.
You asked the Plan to waive the cost share for the laboratory service. You say that you are being charged more than your responsibility. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit the Explanation of Benefits which would provide the allowed amounts for the services and if the deductible had been met. Therefore, the plan has not shown that the deductible and coinsurance amounts you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the cost share for the laboratory services provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for upper partial denture (D5213) and lower partial denture (D5214) provided June 24, 2019.
You asked the Plan to pay for the dental services. You say that your dentist had called and verified that the plan would pay in full for the partial. The dentist is holding on to your partial that you didn't get paid for and can't use until the bill is paid. The Plan denied your request. The Plan says the annual maximum has been exhausted.
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 health plan contract says that once the annual maximum is met you are responsible for all charges. 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 upper partial denture (D5213) and lower partial denture (D5214) provided June 24, 2019.