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

We decided that the Plan does not have to pay for the dental services provided by you, an OON provider.

You asked the Plan to pay for the dental services. You say that your receptionist and the enrollee contacted the Plan and were told that you were a participating provider, and that the services would be covered. The Plan denied your request. The Plan says these services were rendered by you, a non-participating provider. The Plan also says that the enrollee must receive services from 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. The records also show that your office representative was advised twice that your office was not participating with the enrollee's plan. Your representative was also advised that the services would not be covered. Therefore, we decided that the Plan does not have to pay for the dental services provided by you, an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compressor (E0651) and a segmental pneumatic appliance (E0667).

You asked the Plan to pay for a pneumatic compressor and a segmental pneumatic appliance. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are only covered by Medicare for treatment of lymphedema and of chronic venous insufficiency with venous stasis ulcers.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Coverage criteria for a pneumatic compressor are not met. Furthermore, a segmental pneumatic appliance is not separately payable when the base pneumatic compression device is not covered. Therefore, we decided that the Plan does not have to pay for a pneumatic compressor (E0651) and a segmental pneumatic appliance (E0667).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that PET is not covered for initial treatment strategy for prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found while Axumin PET scan is usually not indicated for the initial staging of prostate cancer this enrollee has extenuating circumstance which provide ample indication for the test. Certainly the pathology of the tumor with a sample of Gleason 9 indicates an aggressive tumor. It is known the tumor has already spread beyond the capsule. The oncologist is justified in being concerned whether the pelvic lymph nodes are metastatic in nature since if they are targeted radiation of the prostate area would not be indicated. The pleural effusions are less concerning for prostate metastases. In addition the enrollee has a pacemaker which means conventional imaging with MRI is not possible. In addition the enrollee has stage III chronic renal disease which means extensive CT scans including contrast injection are likely dangerous. The enrollee is also anticoagulated on Eliquis which means percutaneous biopsy would not be advisable. Axumin PET scan is prostate specific and would be the safest and best single test to determine if the therapy the patient is on currently is sufficient or whether target radiation therapy should be considered.

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 scan have been met. Therefore, we decided that the Plan has to pre-approve a PET/CT scan.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses received on September 22, 2020.
You asked the Plan to pay for the frames and lenses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was processed correctly per your plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $250 every two calendar years. We looked at the file and the Plan's rules. The plan covers up to $250 every two calendar years for eyeglasses (frames and lenses). Review of the file shows that you last received eyeglasses on November 12, 2019. Two calendar years had not passed since you previously received frames and lenses. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames and lenses received on September 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on June 9, 2020.
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 the claim has been recoded for CPT 99284.
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation supports a comprehensive history and exam, and medical decision making of moderate complexity. Therefore, the appropriate code to report is CPT 99284. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services rendered on May 8, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the appropriate POS code. We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status in a skilled nursing facility for the date of service at issue and the claim was not billed with the required POS code 32. 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 portable x-ray services rendered on May 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital inpatient care services (99223) provided September 14, 2020.
You asked the Plan to pay for the inpatient services. You say that you have included the complete medical records for review and reconsideration of your claim as medically necessary. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
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 initial hospital inpatient care services (99223) provided September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network member liability for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 23, 2020.
You asked the Plan to waive the out of network member liability for the dental services. You say that the plan's guide clearly states there is a $0 copayment for exams, cleanings, x-rays and fluoride, both in network and out of network. You say that these charges should be covered as a one time exception since it is not apparent from the Medical Plan guide that you should be responsible for these costs. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may bill you for the difference between what the provider charged and what the plan paid.
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, out of network providers may bill you for the difference between what the provider charged and what the plan paid. The member liability is a contractual obligation under the plan and cannot be waived. Therefore, we decided that the Plan does not have to waive the out of network member liability for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services.

You asked the Plan to pay for the office services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services can be processed once the primary insurance
evidence of benefits has been received by the secondary insurance.

The Plan must follow Medicare rules. The rules state 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 Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the office services until the primary insurer has denied the claim for these services. Therefore, we decided
that the Plan does not have to pay for the office services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $325 copayment charged for ambulance transport provided on August 28, 2020.
You asked the Plan to waive the $325 copayment charged for ambulance transport provided on August 28, 2020. You say that you were diagnosed with Covid-19 so this copayment should not apply. The Plan denied your request. The Plan says this copayment was charged per your Plan contract agreement.
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 $325 copayment for each one-way ambulance transport. Medicare is not waiving copayments for services such as ambulance transports due to Covid-19. 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 $325 copayment charged for ambulance transport provided on August 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the records indicate a normal bone mineral density level.
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. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Prolia is medically reasonable and necessary for the patient with normal bone density. As summarized in Drugdex/Micromedex: "Results of 1 trial indicate a fracture reduction benefit of denosumab used in postmenopausal women with hormone receptor-positive breast cancer who were also receiving aromatase inhibitors, but final results of disease-free survival effect are not yet available, so no recommendations for adjuvant denosumab use can be made". 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $125 copayment charged for ambulance transport provided on September 20, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $125 copayment for each one-way ambulance transport. 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 $125 copayment charged for ambulance transport provided on September 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 11,
2020.
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 the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that the denied codes are not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). 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 for laboratory services provided to the
enrollee on March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be rendered in an alternate level of care, such as skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids.

You asked the Plan to pay for hearing aids. You say that you should be reimbursed for this purchase. The Plan denied your request. The Plan says only hearing aids from Plan-participating providers are covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a Plan-participating hearing aid provider.

We looked at the file and the Plan's rules. The hearing aids at issue were not purchased from a Plan provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion interspinous spacer device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion interspinous spacer device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diagnostic radiology provided by a participating provider on November 4, 2020.
You asked the Plan to waive the coinsurance for a PET scan. You say that you thought your copayment would be $250. The Plan denied your request. The Plan says the correct coinsurance has been applied to the PET scan that was provided.
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 20% coinsurance for outpatient diagnostic tests/diagnostic imaging/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for a PET scan. The total allowed amount is $8,812. The total amount you are being asked to pay is $1,762.40 ($8,812 x 20% = $1,762.40). The correct coinsurance has been applied to the PET scan that was provided. A PET scan falls within the outpatient diagnostic tests/diagnostic imaging/in-network 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 diagnostic radiology provided by a participating provider on November 4, 2020.