Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray, periodic oral evaluation, bitewings, clasp addition to existing partial denture, and osseous surgery provided on July 15, 2019.
You asked the Plan to pay for the intraoral periapical x-ray, periodic oral evaluation, bitewings, clasp addition, and osseous surgery. You say that this provider is your assigned dentist. You also say that the work provided was orally necessary due to health risks. The Plan denied your request. The Plan says unless your Plan approves it, the Plan only covers services done by your assigned dentist. The Plan also says that this provider is not a contracted dental 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. 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 additional intraoral periapical x-ray, periodic oral evaluation, bitewings, clasp addition to existing partial denture, and osseous surgery provided on July 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on August 15, 2018 by the out of network provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 psychotherapy services provided on August 15, 2018 by the out of network provider.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee presented to the emergency department from a wound care clinic with redness and swelling to the right foot 2nd toe on 2/3/2020 post op day 4 status post right 2nd toe trans-metatarsal amputation. He has a history of HIV infection, hepatitis C infection, diabetes, hypertension and chronic kidney disease. He has had surgical debridement of bilateral foot wounds (right second toe and left metatarsal area). He has been on intravenous antibiotics - Vancomycin and Zosyn. Four to six weeks of intravenous Zosyn is recommended. He is functionally limited and physical therapy and occupational therapy have been consulted. Transfer to a long term acute care hospital (LTACH) is requested. Based on the provided medical records the acute care hospital is able to provide all of the services the enrollee requires. 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. Based on the provided medical records the enrollee is getting these services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2330) for teeth # 23 and 25 provided on October 17, 2019.
You asked the Plan to pay for the dental services. You say that you contacted the plan on October 15, 2019 to confirm that the provider was a contracting provider. You say that you were advised by the Plan representative that the provider was contracted with the Plan. You also say that you would not have had the fillings done there if the dentist was not in network. The Plan denied your request. The Plan says the provider in this case is not a participating with dentist. The Plan also says that dental service provided by non-participating providers will not be 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 fillings you received are not covered when you receive the services out of network. Therefore, we decided that the Plan does not have to pay for the fillings (D2330) for teeth # 23 and 25 provided on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant for the enrollee.
You asked the Plan to pre-approve Dexilant. You say that the enrollee has been on this medication for years
with good results. The Plan denied your request. The Plan says that this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Dexilant for the enrollee.
Benefits for Dexilant 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) and wrist-hand orthosis (WHO) rendered on September 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an LSO is covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee's chief complaints were back pain and left wrist pain. The available documentation in the case file does not support that the requested
lumbar-sacral orthosis was medically reasonable and necessary for the enrollee. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. The documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the wrist. We looked at this physician's review, the file, and Medicare rules. 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 lumbar-sacral orthosis (LSO) and wrist-hand orthosis (WHO) rendered on September 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 20, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay the bill because the hospital you were at didn't have the necessary equipment. The Plan denied your request. The Plan says that the claim processed 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 $200 copayment for each Medicare-covered ambulance service. You have been asked to pay a $200 copayment for the ambulance transport. the ambulance transport falls within the Medicare-covered ambulance 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 copayment for the ambulance transport provided on October 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable


 We decided that the Plan does not have to waive the cost share for the Part B injection and its administration provided on August 29, 2019. 
 
You asked the Plan to waive the cost share for the Part B injection and its administration. You say that you do not agree with this bill. You say you want it reviewed so you do not have to pay it. 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 Part B chemotherapy drugs and other Part B drugs and a $50 copayment for each Medicarecovered specialist visit.  
 
You have been asked to pay a total of $432.94 for the Part B injection and its administration. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. The administration of the drug falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. See chart below. 
 
Date of Service Service Allowed Amount Coinsurance/Copayment Member Liability

August 29, 2019 Part B injection $1,501.14 20% $382.94 
August 29, 2019 Drug administration 
$110.37 $50.00 $50.00 
Total    $432.94 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the Part B injection and its administration provided on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided on August 2, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 80307 is drug test(s), presumptive, any number of drug
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD,
MALDI, TOF) includes sample validation when performed, per date of service.
We find that CPT code 80307 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug
testing coded 80307 provided on August 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe mammogram or the ultrasound provided on September 13, 2019.You asked the Plan to waive the copayments forthe mammogram and the ultrasound. You say that this was your yearly mammogram and it should be covered. 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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasounds). You have been asked to pay a $40 copayment for the mammogram and a $40 copayment for the ultrasound. The mammogram and the ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the tests were performed because of a lump on your breast which makes the mammogram and ultrasound 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 copayments forthe mammogram or the ultrasound provided on September 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hip orthosis (CPT Code L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (CPT Code L2624) provided to the enrollee on August 15, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
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 hip orthosis (CPT Code L1686) and addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each (CPT Code L2624) provided to the enrollee on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 30, 2019.
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 August 30, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve SNF care. You say that you need this rehab after your 10 day hospital stay. The Plan denied your request. The Plan says that there is a lack of reasonable expectation of functional improvement.
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 SNF care. Our reviewer says that the requested admission is medically reasonable and necessary. Our physician reviewer found the enrollee continues to require significant wound care. The enrollee requires oversight of his medical conditions and medication management. He is at risk for secondary complications of immobility such as further pressure ulcers and worsening contractures. The enrollee requires either physical or occupational therapy to assess his wheelchair and positioning needs and for education of his caregivers in terms of preventing further skin injury. The enrollee requires at least daily nursing services. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis and he has already failed long-term care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on August 16, 2019,
August 20, 2019 and August 30, 2019.
You asked the Plan to pay for the acupuncture services. You say that the acupuncture treatment was for
neurological pain and itching on your back that you have had for over twenty years and your doctors have tried
everything without success. You say that you felt you had to live with this condition and then your doctor
suggested acupuncture. You say the acupuncture treatments have worked and it is less expensive than the
creams and pills that have never worked. The Plan denied your request. The Plan says acupuncture is not a
covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
The contract with the Plan says that acupuncture services are not covered by the Plan under any condition.
The services at issue in this appeal are acupuncture services. Medicare and the Plan do not cover acupuncture
services. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on
August 16, 2019, August 20, 2019 and August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Vive Rollator Walker purchased on July 29, 2019 from an out-of-network provider. 
 
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You were reimbursed the Medicare allowable per the DME Fee Schedule for the purchased out of pocket rollator with seat. Any payment over the Medicare allowable is not payable by Medicare nor the health plan. In addition, sales tax and shipping and handling are not covered by Medicare and not payable by the health plan. Therefore, we decided that the Plan does not have to pay for Vive Rollator Walker purchased on July 29, 2019 from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 28, 2019 to
August 26, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a 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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. 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 July 28, 2019 to August 26, 2019.