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

We decided that the Plan does not have to reduce the coinsurance forthe anesthesia for surgery provided on October 11, 2019.You asked the Plan to reduce the coinsurance forthe surgical anesthesia. You say that you were told this service would be covered at the in-network rate. 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 30% coinsurance for surgery services at an out-of-networkoutpatient hospital. You have been asked to pay $32.58 which is 30% of the allowed amount for the surgical anesthesia. The allowed amount is $108.59. ($108.59 x 30% = $32.58). The surgical anesthesia falls within the "Outpatient hospital services" benefit category. The record shows the provider is out-of-network.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 reduce the coinsurance forthe anesthesia for surgery provided on October 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (77002) provided on August 6, 2019.
You asked the Plan to pay for the fluoroscopic guidance for needle placement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77002-26-59 was billed without an appropriate primary 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, we have confirmed that code the fluoroscopic guidance for needle placement is a Type I add-on code and has not been billed with an appropriate primary procedure code. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (77002) provided on August 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 21, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a valid physician order, laboratory requisition, or medical records stating exactly which testing was to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on June 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee on July 31, 2019 to October 11, 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 claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that a treatment authorization code is required for home health claims. We looked at the file and Medicare rules. The claim was not billed with the required treatment authorization code. 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 home health services rendered to the enrollee on July 31, 2019 to October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefrabricated oral device (E0485).
You asked the Plan to pre-approve the oral device. You say that a dentist recommended a snore guard device. You do not want to use CPAP machine nor do you feel you need that level of prevention. The Plan denied your request. The Plan says this item is not covered by Medicare or the plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on this information, we decided that Medicare rules for coverage of the snore guard oral device have not been met. Therefore, we decided that the Plan does not have to pre-approve a prefrabricated oral device (E0485).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe restorative procedures (D2999 x2), sinus augmentation (D7951), and endosteal implants (D6010) for tooth #'s 11 & 12.You asked the Plan to pre-approvethe restorative procedures (D2999 x2), sinus augmentation (D7951), and endosteal implants (D6010) for tooth #'s 11 & 12. You say that you need these services because the dentures do not stay in place. You also say thatthese services are medically necessary.The Plan denied your request. The Plan says unspecified restorative procedure and sinus augmentation are not covered benefits. The Plan also says that the number of times you can have endosteal implants has been reached.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, unspecified restorative procedure (D2999) and sinus augmentation (D7951) are not among those covered under this benefit. The contract also clearly states that only two implant services are allowed per calendar year. The record shows that two endosteal implants (D6010) were approved on January 19, 2020 and your implant services benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvethe restorative procedures (D2999 x2), sinus augmentation (D7951), and endosteal implants (D6010) for tooth #'s 11 & 12
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the rendering facility is a non-participating provider.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 forphysician services provided on November 21, 2019 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular
partial denture (D5214).
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you decided to
stop wearing your partials due to sores in your mouth. You also say that it took too long, and the partials did
not fit when you tried them back on. The Plan denied your request. The Plan says these services exceed the
maximum count allowed per period.
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, maxillary partial denture (D5213) and
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows
that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on March 20,
2019 and your partial dentures benefit is now exhausted. Therefore, we decided that the Plan does not have to
pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit provided on September 5, 2019 and cardiovascular monitoring provided on September 26, 2019.You asked the Plan to waive the cost share for the office visit and cardiovascular monitoring. You say that you were not advised the provider is out-of-network. You say that you were advised your copayment should be $35.The Plan denied your request. The Plan says the cost share applied correctly.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 your combined in and out-of-network deductible is $183. This is the amount you have to pay out-of-pocket before the Plan will pay its share for your covered Medicare Part A and B services. Your contract with the Plan says that you must pay 20% of the cost for each out-of-network specialist visit for Medicare-covered benefits and 20% of the cost for Medicare-covered diagnostic procedures or tests.The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category and "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $183 deductible applies to office visits and outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the office visit and cardiovascular monitoring was received on September 5, 2019 to September 26, 2019.Therefore, $183 was applied to meet your deductible.Since your $183 deductible was met, you have also been asked to pay $158.25, which is 20% of the allowed amount for the office visit and cardiovascular monitoring. The total amount you owe is $341.25 ($183 + $158.25 = $341.25).The records show that the provider is out-of-network. 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 office visit provided on September 5, 2019 and cardiovascular monitoring provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trigger point injections for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that trigger point injections are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic myofascial pain and bipolar disorder. He has been receiving trigger point injections every six to eight weeks for more than a year. There is no diagram of the trigger points and radiation from each of the muscular bands. There is no documentation of effectiveness and duration of pain relief. There is a lack of documentation of where the trigger points are, their characteristic radiation patterns as well as no documentation as to effectiveness and duration of relief. The requested procedure 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve trigger point injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 9, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you only had one stitch taken out. You say that you want the copayment reviewed. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for services obtained from a specialist. You have been asked to pay a $45 copayment for the office visit. The 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 the office visit provided on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve water circulating cold pad with pump (E0218).
You asked the Plan to pre-approve water circulating cold pad with pump. You say that this item is medically necessary and you would like to appeal the denial of coverage. The Plan denied your request. The Plan says the requested item is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of water circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve water circulating cold pad with pump (E0218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).You asked the Plan to pre-approvethe maxillary partial denture. You say that you lost your previous denture.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan'scoverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, partial dentures are limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) on June12, 2018 and your partial dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture (D5213)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on February 5, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says a valid order was not submitted.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on February 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you feel that additional SNF days should be covered because you have another surgery coming up and your records will support that you will need to stay at a SNF. The Plan denied your request. The Plan says the 100 day SNF benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from November 4, 2019 to February 26, 2019. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 records do not show a requirement for an intensive team for care.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 the enrollee's 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 the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does 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-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 pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).You asked the Plan to pre-approvethe dental services. You say that you need replacement dentures sooner than 60 months. You say that you had partial dentures before but you had the rest of your teeth removed so they no longer work for you.The Plan denied your request. The Plan says dentures are covered once every 60 months. The Plan says that the frequency limit has been reached. The Plan also says that dentures are considered dental in nature.Medicare generally does notcover 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 coverageand dentures are a covered service, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on July 18, 2017.Additionally, the services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forstrapping and wound debridement provided on September 19, 2019 and September 26, 2019.You asked the Plan to waive the copayments forstrapping and wound debridement. You say that you feel that the charges are exorbitant.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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received strapping at an outpatient hospital facility on September 19, 2019. Strapping is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $157.66, which is less than the $295 copayment. You received wound debridement at an outpatient hospital facility on September 26, 2019. Wound debridement is considered an outpatient procedure. Therefore, you are responsible to pay the allowed amount of $206.65. The total amount you owe is: $364.31.You have been asked to pay the total copayment amount of $364.31 for strapping and wound debridement. Strapping and wound debridement fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forstrapping and wound debridement provided on September 19, 2019 and September 26, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit at PROVIDER on September 21, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you 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 $85 copayment for emergency care. You have been asked to pay a $85 copayment for an ER visit. An ER visit falls within the emergency 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 ER visit at PROVIDER on September 21, 2019.