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

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on August 28, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on August 28, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for the specialist office visits provided on June 14, 2019
and July 11, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you should not be
responsible for the copayments because you do not think the nerve study was needed and the doctor only gave
you x-ray results. 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. There were no Explanations of Benefit or claim forms submitted with the code at
issue to verify the billed services. Therefore, the plan has not shown that the copayment amount 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 copayments for the specialist office visits provided on June 14, 2019 and July 11, 2019.
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.
Your complaint about the poor service at the doctor's office 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forpsychotherapy provided from January 9, 2019 through June 20, 2019.You asked the Plan to waive the copayments forpsychotherapy. You say that you paid $75 per visit. You say that you should be reimbursed more.The Plan denied your request. The Plan says the copayments 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 $40 copayment for each Medicare-covered individual therapy session from an in-network provider.You have been asked to pay a $40 copayment for each psychotherapy visit. The total amount you owe is $440 ($40/visit x 11 visits = $440). Psychotherapy falls within the "Outpatient Mental Health Care" 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 forpsychotherapy provided from January 9, 2019 through June 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says needs can be met at a lower level of care, such as subacute rehabilitation.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that you require the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of PT and OT but you do not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided on August 2, 2019.You asked the Plan to pay forthe orthoses. You say that the provided records should support the necessity of the services in dispute.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telemedicine or telehealth service with the ordering physician as required per CMS guidelines.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 meansthat 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 non-covered visit are likewise non-covered.Therefore, we decided thatthe Plan does not have to pay forknee orthosis (L1851) and suspension sleeve (L2397) provided on August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion decompression device.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process (22869). You say that the enrollee would benefit from this less invasive approach. The Plan denied your request. The Plan says this device is contraindicated by the manufacturer and FDA for this enrollee.
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 insertion of interlaminar/interspinous process (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental, more research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion decompression device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe (J0897).
You asked the Plan to pre-approve this medication. You say that Prolia is medically necessary as the enrollee has Osteoporosis. The Plan denied your request. The Plan says certain criteria must be met for coverage of this drug. Documentation with information meeting this criteria was not received. For your condition, use of this drug must meet one of these criteria for a diagnosis of osteoporosis: Either a history of osteoporotic fracture; or failure or contraindication to zoledronic acid (our step therapy alternative). Step therapy encourages you to try our preferred drug, which is just as effective.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this medication. Our reviewer says that the enrollee does not meet criteria for coverage of the medication Prolia. Our physician reviewer found the patient has not tried and failed the required drug. The documentation does not support that the preferred drug Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Additionally, the documentation does not demonstrate a history of an osteoporotic fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml syringe (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from August 9, 2019 to August 16, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that no one ever explained the inpatient hospital benefit. You say you are on a limited income. 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 $200 copayment for day 1 and $25 copayment each day for days 2 to 5 for in-network Medicare-covered hospital care and a $0 copayment for additional Medicare covered days. You have been asked to pay a total of $300 for the inpatient hospital stay. ($200 for Day 1, $100 for Days 2-5, and $0 for Days 6-7). The inpatient hospital stay falls within the "Inpatient Hospital Care" 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 foran inpatient hospital stay provided from August 9, 2019 to August 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 27, 2019
to September 13, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient skilled nursing facility level of care.
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 pay for the skilled nursing services. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily
skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional
nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and
judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled
therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from August 27, 2019 to September 13,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain or ceramic crown provided on February 28, 2019.You asked the Plan to pay forthe crown. You say that the best clinical treatment was to remove all caries and undermined enamel and place a full coverage crown to restorefull form and function on the tooth. You also say that this treatment provided the best long-term prognosis for tooth #10.The Plan denied your request. The Plan says no benefits are available for the treatment of wear.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These aredental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe porcelain or ceramic crown provided on February 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 11, 2019 by an out-of-network provider.
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 services were rendered by an out-of-network provider without 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 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 medical services provided on March 11, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning rendered to you on October 28, 2019.
You asked the Plan to pay for these services. You say that you didn't know you had to use a participating provider. The Plan denied your request. The Plan says the services were not performed by a participating provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a participating provider. Review of the file shows that you received services from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental cleaning rendered to you on October 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room services rendered to the enrollee on April 4, 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 separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99285 and 99220. Code 99285 is a column II code with a modifier indicator of 1 when billed with column I code 99220. Code 99285 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe emergency room services rendered to the enrollee on April 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant provided on June 18, 2019.You asked the Plan to pay forthe endosteal implant. You say that prior to the services being rendered you were told multiple times that dental implants are covered under your plan with a 50% coinsurance.You also say that you were told that implants are not a covered service.The Plan denied your request. The Plan says they made payment to the non-contracted provider in the amount of $1,235. The Plan also says that your 50% coinsurance for comprehensive dental services performed out-of-network applied.Medicare generally does not cover dental services. However, the Plan offers adental 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. The Plan made a payment in the amount of $1,235 as a courtesy for one implant. Therefore, we decided that the Plan does not have to pay forthe endosteal implant provided on June 18, 2019.Your complaint about being disappointed with the information you have received 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the colonoscopy and the laboratory work provided on May 30, 2019.You asked the Plan to waive the coinsurance for the colonoscopy and the lab work. You say that you were told a modified biopsy was completed during your colonoscopy. You say the screening was clear and no polyps were removed.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 25% of the cost at an in-network outpatient hospital and 10% of the cost for in-network laboratory services. You have been asked to pay a total of $290.48 for the colonoscopy and the laboratory work. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows a biopsy was performed which makes the colonoscopy diagnostic in nature.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 colonoscopy and the laboratory work provided on May 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveDexamethasone Sodium Phosphate for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information shows enrollment in a clinical trial.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the differencebetween the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve the services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plandoes not haveto pre-approveDexamethasone Sodium Phosphate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of broken teeth, per tooth (D5640) for teeth
# 5, 6, 11, 12, and 13, and the repair of a broken complete lower denture base (D5512) provided on October 15,
2019.
You asked the Plan to pay for the dental services. You say that you are being billed more for the services you
received than what you receive in Social Security per month. The Plan denied your request. The Plan says the
denture repair services you received are not covered.
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 denture repair services that you
received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the replacement of broken teeth, per tooth (D5640) for teeth # 5, 6, 11, 12, and 13, and the repair of a
broken complete lower denture base (D5512) provided on October 15, 2019.