Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric seat lift, variable height Hi-Lo hospital bed, foam 
rubber mattress, full length bedside rails, commode chair with fixed arms, patient lift, electric with sling or 
seat, patient lift, canvas or nylon, hydraulic lift, full mesh body swing, and bedside remote controller provided 
on February 9, 2020 to February 19, 2020 by an various out of network (OON) providers. 
 
You asked the Plan to pay for the durable medical equipment. You say that you are appealing the denial for 
expenses incurred to provide necessary equipment to the enrollee. You were told by a plan representative that 
the services are covered and you request reimbursement. The Plan denied your request. The Plan says the items 
were obtained from providers who are not under contract with the health plan and are not certified for 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical 
care as long as the care you receive is considered medically necessary and you receive your care from a 
provider who is eligible to provide services under Original Medicare. If you go to a provider who is not eligible 
to participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The providers in this case are not certified Medicare suppliers and are not contracted with the Plan. The Plan 
has verified that there were network providers available who can provide the items/services at issue in this 
appeal. 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 electric seat lift, variable height Hi-Lo hospital bed, foam 
rubber mattress, full length bedside rails, commode chair with fixed arms, patient lift, electric with sling or 
seat, patient lift, canvas or nylon, hydraulic lift, full mesh body swing, and bedside remote controller provided 
on February 9, 2020 to February 19, 2020 from various out of network (OON) providers.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foran emergency room visit and inpatient stay on June 23 to June 26, 2019.You asked the Plan to waive the copayments forthe emergency room visit and inpatient stay. You say that the copayment was applied incorrectly.The Plan denied your request. The Plan says the correct copayments were applied.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 Emergency Care and a $300 per day copayment for inpatient days 1-6.You have been asked to pay a $90 copayment for an Emergency Room visit and a $900 copayment for 3 days of inpatient care, at $300 per day. 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 foran emergency room visit and inpatient stay on June 23 to June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 22, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysaccording to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of serviceHCPCS G0483:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) andlc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 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 are not supported by the medical records. Our physician reviewer found no provider records have been submitted for review. Therefore, there isno documentation of a provider's concern for drug abuse/misuse. There is no evidence that the UDS results were reviewed prior to ordering the UDT. There is no evidence that the UDT was tailored to the enrollee's addictions and/or medications. Therefore, the documentation does not support that the provided UDS and UDT were medically necessary or 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 services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal maintenance provided on January 7, 2020.You asked the Plan to pay forperiodontal maintenance. You say that you have never had to pay for this non covered service in the past.The Plan denied your request. The Plan says the 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 forperiodontal maintenance provided on January 7, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist hand orthosis (L3908) provided on February 13, 2020.You asked the Plan topay forthe wrist hand orthosis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there is a valid right upper limb diagnosis for carpal tunnel syndrome that should have been submitted for this claim.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code L3908 RT is not supported in the record. Specifically, the ICD-10-CM Official Guidelines for Coding andReporting state that it is not appropriate to report an unspecified, left, right or bilateral diagnosis code when the procedure being performed has a modifier on the claim that does not match the diagnosis code. The diagnosis code submitted on the claim indicates an unspecified upper limb diagnosis. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis have not been met.Therefore, we decided that the Plan does not have to pay forwrist hand orthosis (L3908) provided on February 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora laryngoscopy provided onFebruary 13, 2020.You asked the Plan to waive the copayment fora laryngoscopy. You say that you feel that the laryngoscopy should not be considered 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 $380 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $171.48, which is less than the $380 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient surgery and other medical 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 fora laryngoscopy provided on February 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveresin-based composites (codes D2330 and D2394) and a maxillary partial denture.You asked the Plan to pre-approvethe resin-based composites and a maxillary partial denture.. You say that you feel these services should be approved because you feel it is necessary work.The Plan denied your request. The Plan says these services are not covered under your plan.Medicaregenerally 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, therequested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveresin-based composites (codes D2330 and D2394) and a maxillary partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home visit (99349) provided on May 31, 2019.You asked the Plan to pay forthe home visit. You say thatyou would like reconsideration based on the records submitted,The Plan denied your request. The Plan says the documentation indicates that these services are not necessary for the treatment of the member's condition.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 99349 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed 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 presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with thepatient and/or family. We find that CPT code 99349 is not supported in the record. Specifically, the record indicates that this service was rendered by a licensed vocational nurse. There is no evidence that a physician was present in the beneficiary's home. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met.Therefore, we decided that the Plan does not have to pay forthe home visit (99349) provided on May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the out-of-network office visit you had on 
February 25, 2020. 
 
You asked the Plan to waive the coinsurance. You say that this was an urgent care visit. The Plan denied your 
request. The Plan says you are responsible for the coinsurance 
 
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 30% 
coinsurance for Point-of-Service coverage.  
 
Review of the file shows that you had an out-of-network office visit on February 25, 2020. Your plan covers 
out-of-network services under the Point-of-Service benefit. You have been asked to pay a 30% coinsurance for 
the visit, totaling $31.22. The visit falls within the Point-of-Service 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 out-of-network office visit you had on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network dermatology services provided on March 16, 2020. You asked the Plan to pay forout of network services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.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 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. The Plan did not pre-approve the service at issue. 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 forout of network dermatology services provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 6, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
services at issue. 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 physician's services provided on February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

e decided that the Plan does not have to pre-approvegated heart planar single (nuclear stress test).You asked the Plan to pre-approvegated heart planar single. 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 follows Medicare rules. Medicare rules say that nuclear stress tests are only covered for certain indications.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 gated heart planar single. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found a nuclear stress test on March 21, 2019 was reported to be normal including a left ventricular ejection fraction of 80%. A clinic note dated July 23, 2020 documents no recurrent dyspnea or chest pain, a normal cardiac physical exam and a normal electrocardiogram. The documentation supports that the enrollee has some cardiac risk but no ongoing cardiac symptoms, no cardiac exam abnormalities, no electrocardiogram abnormalities and a prior normal nuclear stress test less than two years ago. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gated heart planar single have not been met. Therefore, we decided that the Plan does not have to pre-approvegated heart planar single (nuclear stress test).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora nuclear medicine study and an ultrasound provided on February 25, 2020.You asked the Plan to waive the copayment forimaging services. You say that the hospital made a mistake and scheduled these tests without prior authorization.The Plan denied your request. The Plan says the copayment you are being charged is correct.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 each in-network Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for each of the two imaging service, totaling $200. Nuclear medicine studies and ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Suppliesbenefit 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 fora nuclear medicine study and an ultrasound provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from January 2, 2020 to January 
13, 2020. 
 
You asked the Plan to pay for the physical therapy. 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 
services at issue. 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 physical therapy provided from January 2, 2020 to January 13, 
2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe comprehensive oral evaluation and additional intraoral periapical x-ray. We decided that the Plan does not have to pay forthe oral hygiene instructions. You asked the Plan to pay forthe comprehensive oral evaluation, additional intraoral periapical x-ray, and oral hygiene instructions. You say that the services should be covered because you have had insurance for 5 years and never used it. You also say that the provider charged you for two exams for the same issue on the same day.The Plan says that oral hygiene instructions is not a covered benefit. The Plan also says that the oral evaluation and periapical x-ray have exceeded the benefit limitations.We decided that the Planhas to pay forthe comprehensive oral evaluation and additional intraoral periapical x-ray. 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 provide evidence that the frequency limitations for oral examinations and periapical x-rays had been met. Without this information we cannotdetermine that the Plan's coverage rules support the denial of payment in this case. The Plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe comprehensive oral evaluation and additional intraoral periapical x-ray. We also decided that the Plandoes not have to pay forthe oral hygiene instructions.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 oral hygiene instructions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cinacalcet. 
 
You asked the Plan to pre-approve Cinacalcet. You say that you would like the plan to reconsider their denial 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Cinacalcet.  
 
Benefits for Cinacalcet may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.