Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on October
23, 2019.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you only paid $20 for the
Prolia injection with your previous coverage. 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 each in-network, Medicare-covered Part B drug.
You have been asked to pay $229.20, which is 20% of the allowed amount for the Prolia injection. The allowed
amount is $1,146 (20% x $1,146 = $229.20). The Prolia injection 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 Prolia injection provided on
October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an out of network (OON) 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 December 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (S9999, A9999) provided December 6, 2019.
You asked the Plan to pay for the foot orthotics. You say that the foot arch supports were medically necessary.
The Plan denied your request. The Plan says the arch supports are not a covered benefit. There was no
physician order and no medical records were provided.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order documentation for the items
at issue in this appeal. The record does not contain a valid physician order in this case. Therefore, we decided
that the Plan does not have to pay for foot orthotics (S9999, A9999) provided December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 27, 2019.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery or a deliver ticket for the items at issue in this appeal. The record does not contain a valid proof of delivery, or a delivery ticket for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive ventilator (E0466) to be provided by an
out of network (OON) provider.
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan
denied your request. The Plan says there are network providers that can provide the item at issue.
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-approve
a non-invasive ventilator (E0466) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 26, 2019.You asked the Plan to waive the copayment for an office visit. You say that are being charged a copayment for an annual wellness visit because you asked the provider about a prescription.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 $15 copayment for primary care provider visits.The record shows that you received services beyond an annual wellness visit. Therefore, you are responsible to pay the $15 copayment.  You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with limited field of view (D0364) provided on February 6, 2020.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that your root canal procedure should have been covered. The Plan denied your request. The Plan says this 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 for the cone beam CT capture and interpretation with limited field of view (D0364) provided on February 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided.
You asked the Plan to pay for the laboratory testing. You say that the claim was denied for the records not supporting the services that were billed. You also say that a corrected claim has been submitted with organism sheet for reconsideration of payment. The Plan denied your request. The Plan says during the enrollee's hospice election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the drug testing provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.
You asked the Plan to pre-approve a home ventilator. The Plan denied your request. The Plan says that this 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. Our reviewer says that a home ventilator is not medically reasonable and necessary for the enrollee. The submitted medical records do not report respiratory failure due to neuromuscular disease, thoracic restrictive disease, or chronic obstructive pulmonary disease to the degree that necessitates a home ventilator. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cancer abatement procedure 
You asked the Plan to waive the cost share for the cancer abatement procedure. You say that you should be reimbursed for your surgery. 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. Your contract with the Plan says that there is a $750 deductible that applies towards out-of-network outpatient surgery and 40% coinsurance for out-of-network Medicare-covered outpatient surgery after you pay your $750 deductible. The cancer ablation procedure you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the cancer ablation procedure and 40% coinsurance for out-of-network Medicare-covered outpatient surgery after you pay your $750 deductible. See chart belowDate of Service
Service
Allowed Amount
Deductible/
Coinsurance
Member Liability
July 10, 2019
Cancer ablation procedure
$6,170.69
$750.00
$648.06 - This is where you met your deductible amount
$5,522.63 - This is the remaining allowed amount. ($6,170.69 - $648.06)
40%
$1,849.03 - This is less than the standard amount because the Plan waived the allowed amount for procedure code C1889.
Total
$2,497.09
Please note, the record shows the Plan has reimbursed you $3,247.33 on November 17, 2019 and $19,255.58 on March 20, 2020. ($3,247.33 + $19,255.58 = $22,502.91). ($25,000 - $22,502.91 = $2,497.09).
This cost sharing is a contractual obligation that had not been met at the time the cancer abatement procedure was received on July 10, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the cancer abatement procedure
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the insertion of a breast prosthesis, a biopsy and an inpatient hospital stay
You asked the Plan to waive the copayments for the insertion of a breast prosthesis, a biopsy and an inpatient hospital stay. You say that you were misinformed of the charges and disagree with the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $295 copayment for each day for days 1-4 for inpatient hospital care. You received the insertion of a breast prosthesis on October 7, 2019. The insertion of a breast prosthesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You received a biopsy on November 7, 2019. A biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You received an inpatient hospital stay from November 16, 2019 to November 20, 2019. Therefore, you are responsible to pay a $295 copayment for days 1-4 (November 16, 2019 to November 19, 2019). $295 (copayment) x 4 (inpatient days) = $1,180. The total amount you owe is: $1,730.00.
You have been asked to pay the total copayment amount of $1,730.00 for the insertion of a breast prosthesis, a biopsy and an inpatient hospital stay. The insertion of a breast prosthesis and a biopsy fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. An 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 copayments for the insertion of a breast prosthesis, a biopsy and an inpatient hospital stay
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for a total hip replacement.
You asked the Plan to pre-approve inpatient admission for a total hip replacement. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 inpatient admission for a total hip replacement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there is no clinical rationale for an inpatient hospital admission for the procedure. Most often, an observation level of care lasts for 24 to 48 hours. After that time, based on how the enrollee has responded to the treatment, a decision will be made by the doctor to continue the enrollee's care and have them admitted as an inpatient or to release them to go home. The requested inpatient hospital admission for a left total hip replacement is not medically reasonable or 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 inpatient admission for a total hip replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for a total hip replacement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute rehabilitation facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis coded L3916 provided on December 27, 2019.You asked the Plan to pay forthe wrist hand orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the documentation does not support discussion of theneed for the supply code.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 L3916 is wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf.We find that CPT code L3916 is not supported in the medical record. Specifically, the documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore, the billed supply code cannot be verified. Based on this information, we decided that Medicarerules for coverage of the wrist hand orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthosis coded L3916 provided on December 27, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on August 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for an x-ray. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.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 an x-ray provided on August 21, 2019by an out of network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging provided.
You asked the Plan to waive the coinsurance for the myocardial perfusion imaging. You say that you received a letter indicating that tests were approved and covered. You say that it did not indicate that you would be charged. 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 each Medicare-covered radiological diagnostic service. You have been asked to pay $258.73, which is 20% of the allowed amount for the myocardial perfusion imaging. The allowed amount is $1,293.63 (20% x $1,293.63 = $258.73). The myocardial perfusion imaging falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 2.You asked the Plan to pre-approvethe core build up. You say that a crown is needed to protect the root canal that was previously done on this tooth. You also say that without the requested crown, the tooth may fracture in the future.The Plan denied your request. The Plan says core build up is not listed as a covered service.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, core build up is not among those covered under this benefit.Therefore,we decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 2.