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

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on
November 22, 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 this is not a valid code for an assistant surgeon.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code
29848. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore,
we decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on
November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Digoxin tablets.
You asked the Plan to pre-approve Digoxin tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Digoxin tablets are not covered under the enrollee's Medicare Part B 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 Digoxin tablets.
Benefits for Digoxin tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tab 5mgYou asked the Planto pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the medication does not fall under Part B -it is a Part D drug.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 Prednisone tab 5mg
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea portable oxygen concentrator. You say that you would like a portable oxygen concentrator to leave home.The Plan denied your request. The Plan says that a portable oxygen concentrator is available in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator to be provided by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided from September 12, 2017 to November 1, 2019.
You asked the Plan to reimburse you for the dental services. You say that you were given periodontal services without your knowledge or consent. You say that nobody told you that there were cost shares associated with periodontal services. You also say that due to this, you should receive reimbursement for the services. The Plan denied your request. The Plan says your dental benefits were applied correctly for the periodontic services.
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 periodontal maintenance is a covered service, the cost sharing amounts were applied to the dental services correctly.
Date of Service
Billed
Allowed
Deductible
Coinsurance (30%)
Your Responsibility
9/12/2017
$202
$202
$50 for 2017
$45.60
$95.60
4/29/2019
$214
$214
$50 for 2019
$49.20
$99.20
11/1/2019
$214
$214
$0
$64.20
$64.20
TOTAL:
$259
The Evidence of Coverage clearly states there is a 30% coinsurance for periodontal services after the $50 deductible has been met each year. Cost sharing amounts are a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the record shows that you stated in your initial grievance that you were advised when you signed up for Medicare coverage that you would have to pay for these cleanings. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided from September 12, 2017 to November 1, 2019.
Your complaint about receiving the periodontal maintenance without your knowledge or consent is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laser surgery provided on December 9, 2019.You asked the Plan to waive the copayment for laser surgery. You say that you were not informed of the copayment prior to it being imposed. You say that the Plan should be responsible.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 $175 forMedicare-covered surgery services at an in-network ambulatory surgical center.You have been asked to pay a $175 copayment for the laser surgery. The laser surgery 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 forlaser surgery provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pay forthe services (A9502) provided on October 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is a duplicate billing.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules.The services in question were billed on a duplicate claim line. Duplicate claim lines are not payable.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 forthe services (A9502) provided on October 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vascular duplex scan or the extracranial duplex scan provided on December 2, 2019.
You asked the Plan to waive the coinsurance for the vascular duplex scan and the extracranial duplex scan. You say that the tests were necessary and you should not be liable. You say you do not know why you are paying so much. 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 20% coinsurance for outpatient hospital services. You have been asked to pay a total of $107.42 for the vascular duplex scan and the extracranial duplex scan. The vascular duplex scan and the extracranial duplex scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
December 2, 2019
Vascular duplex scan
$268.56
20%
$53.71
December 2, 2019
Extracranial duplex scan
$268.56
20%
$53.71
Total
$107.42
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 vascular duplex scan or the extracranial duplex scan provided on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you have no bottom teeth and
need to get partials because you are not able to chew food. You say that this is medically necessary. The Plan
denied your request. The Plan says this service is not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for the enrollee for Budesonide.
You asked the Plan to pre-approve a tier exception for the enrollee for Budesonide. You say that a tier exception for the enrollee for Budesonide is requested due to cost. The Plan denied your request. The Plan says Medicare does not allow tier exceptions to Medicare Part B drugs.
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. The rules say Plans must provide clear cost share information. The Plan contract clearly states there is a 20% coinsurance for Medicare Part B drugs. There is no contractual tier benefit for Medicare Part B drugs. Medicare does not make exceptions to the cost share for Medicare Part B drugs. Therefore, we decided that the Plan does not have to pre-approve a tier exception for the enrollee for Budesonide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible fora specialist visit provided on May 1, 2019.You asked the Plan to waive the deductible fora specialist visit. You say that you disagree with the out-of-network provider 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. Your contract with the Plan says that there is a $1,000 deductible for out-of-network physician/practitioner services, including doctor's office visits. You had a specialist visit provided by an out-of-network provider on May 1, 2019. The record shows that you paid $0 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowedamount of $104.73. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on May 1, 2019.Therefore, we decided that the Plan does not have to waive the deductible fora specialist visit provided on May 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee out of network on
November 12, 2019.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network genetic testing.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that
plans can require prior authorization for services. The contract with the Plan says that the Plan must pay for
care from out-of-network providers only in cases involving emergencies, out of area urgent care and preapproved
care. The contract with the Plan specifically states that genetic testing both in and out of network
requires prior authorization.
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve genetic testing
for the enrollee. We found no exception that would require the Plan to pay for this testing. Therefore, we
decided that the Plan does not have to pay for genetic testing provided on November 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says there is insufficient documentation to confirm medical necessity for this transition to SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. You do not have complex wound care or other SNF level skilled nursing need. You do not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ALS emergency ambulance services (A0427) and ground mileage (A0425) provided August 3, 2019. You asked the Plan to pay for the ambulance services. You say that please review and reprocess for payment. The Plan denied your request. The Plan says that the no fault carrier's payment exceeded the plan's allowable.
The Plan must follow Medicare rules. Medicare rules say that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The auto carrier, covered 80% of the billed charges as the primary payer. The actual charge of $701.00 minus the primary payment of $561.60 = $139.40. Therefore, the plan, has to pay the secondary payment in the amount of $139.40. Therefore, we decided that the Plan has to pay for the ALS emergency ambulance services (A0427) and ground mileage (A0425) provided August 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on
August 15, 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 Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis
(L1971) provided to the enrollee on August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two posterior resin-based composites and two anterior resin-based composites provided on November 4, 2019.You asked the Plan to pay for the resin-based composites. You say that you signed some documents saying if the services were not covered by insurance that you would have to pay. You also say that the provider contacted your insurance and they told you that the Plan had accepted four fillings, but did not tell you that your coverage was exhausted.The Plan denied your request. The Plan says this benefit was 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, amalgam or resin-based composite fillings are limited to two procedures per calendar year. The record shows that you received 6 resin-based composites on November 4, 2019, two of which were paid for by the Plan, and your amalgam and resin-based composite benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the two posterior resin-based composites and two anterior resin-based composites provided on November 4, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea surgical knee arthroscopy with medial and lateral meniscectomy (29880).You asked the Plan to pre-approvea surgical knee arthroscopy with medial and lateral meniscectomy. You say that this is a necessary aspect of the surgery.The Plan denied your request. The Plan says the lateral meniscus appears intact.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a surgical knee arthroscopy with medial and lateral meniscectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Plan has approved right knee surgery to include medial meniscectomy and chondroplasty (CPT codes 29879 and 29881). In this case, there is no imaging evidence of a lateral meniscus tear or discussion of a suspected lateral meniscus tear to support the medical necessity of CPT code 29880 in addition to the approved procedures. Therefore, this request would not be considered medically reasonable and necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a surgical knee arthroscopy with medial and lateral meniscectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvea surgical knee arthroscopy with medial and lateral meniscectomy (29880).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for chiropractic services to be rendered by an out-of-network provider. You asked the Plan to pre-approve the in-network exception. You say that you would like reconsideration because the member has tried all recommended and traditional means to treat their condition. The Plan denied your request. The Plan says there are in-network chiropractors available to render the 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). We looked at your request, the file and the rules. Based on this information we decided that the Plan's rules for an in-network exception have not been met. Specifically, the record indicates that there are chiropractors available to render this service within the Plan's network. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for chiropractic services to be rendered by an out-of-network provider.