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

We decided that the Plan has to pre-approve a plastic surgery consult for a split earlobe.You asked the Plan to pre-approve the consult. You say that this is medically necessary.The Plan denied your request. The Plan says that the clinical exam showed no proof of functional impairment from the earlobe split.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 consult. Our reviewer says that the requested consult is considered medically reasonable and necessary in this case. Our physician reviewer found cosmetic surgery is not at issue in this case, but rather consultation with a plastic surgeon regarding a split earlobe. The documentation supports that consultation with a plastic surgeon is medically reasonable and necessary for the diagnosis or treatment of your injury.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 consult have been met.Therefore, we decided that the Plan has to pre-approve a plastic surgery consult for a split earlobe.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from October 14, 2019 to October 20, 2019.
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 RAP is required to process final, per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed correctly. A review of the file shows no RAP claim entered into the system. 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 home health services provided to the enrollee from October 14, 2019 to October 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power lift recliner, tax and warranty
You asked the Plan to pay for the recliner tax and warranty, the transport chair, and the wheelchair ramp. You say that you need these items and the Plan should reimburse you. The Plan denied your request. The Plan says they do not reimburse sales tax or warranties, the transport chair was not medically necessary, and the wheelchair ramp does not primarily serve a medical purpose.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Durable medical equipment purchased privately through agents are not eligible for coverage by your Medicare governed health plan. Therefore the plan is not required to pay the full cost of these supplies. We looked at the file and Medicare rules. Sales tax and warranties are not separately payable by Medicare. Based on this information, we decided that Medicare rules for coverage of the recliner tax and warranty, the transport chair, and the wheelchair ramp have not been met. Therefore, we decided that the Plan does not have to pay for the power lift recliner, tax and warranty
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for an outpatient clinic visit (G0463) and urinalysis (81002) provided on December 20, 2019.. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the member does not have out-of-network benefits.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 20, 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 crown-porcelain fused to high noble metal tooth 22
(D2750).
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration as your
dentist recommended full coverage of the crown to prevent future fracture or recurrent decay of the tooth and
establish proper and protective function. The Plan denied your request. The Plan says the requested procedure
is not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
services when the services are medically necessary and reasonable.
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 dental services. Our reviewer says
that thee requested item is not medically necessary for Our physician reviewer found in this instance, there is
sufficient remaining structure that a crown would not appear to be necessary to prevent fracture. Admittedly the
provided x-ray is not of the most diagnostic quality, but given what can be seen on the film there appears to be
sufficient remaining structure such that a crown would not be deemed medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve crown-porcelain fused to high noble metal tooth 22 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 30, 2019.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT code G9226 has a status indicator of M and the claim submitted denied for OCE 72 per Medicare payment guidelines. The Plan states they will accept a corrected claim for payment reconsideration for all claim lines.Therefore, we decided that the Plan does not have to pay for the physician services provided on September 30, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that the requested bath chair should be covered because you have to walk with two canes just to get around. You say that you have fallen before and do not want to fall again. You stated that your insurance company is not helping you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care assistance, protective supervision, and delegated tasks services.
You asked the Plan to pre-approve custodial care services. You say that you need to back to work full-time but the enrollee requires care. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are custodial care in nature and are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that custodial care services are not covered. We looked at the file and Medicare rules. The requested services are custodial care in nature, and therefore are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of custodial care services have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care assistance, protective supervision, and delegated tasks services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the repair of a detached retina provided at an outpatient hospital facility on September 6, 2019.
You asked the Plan to waive the coinsurance for the repair of a detached retina. 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the repair of a detached retina on September 6, 2019. The repair of a detached retina is considered an outpatient surgical procedure. The allowed amount is $4,257.72 and 20% of that is $851.54. You have been asked to pay the total coinsurance amount of $851.54 for the repair of a detached retina. The repair of a detached retina falls within the outpatient surgery, including 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 coinsurance for the repair of a detached retina provided at an outpatient hospital facility on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for lower extremity edema.The Plan denied your request. The Plan says gradient compression stockings are non-covered when there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 31, 2019 by an out of network (OON) provider.You asked the Plan to pay forclinic services. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, becausethis provider is out-of-network with the Plan and the enrollee self-directed for service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided on July 31, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a back brace (L0648KX) provided on
January 20, 2020.
You asked the Plan to waive the copayment for the back brace. You say that you did not want the brace so you
should not be responsible for the charges. The Plan denied your request. The Plan says based on Medicare
billing criteria, the claim was billed 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 20%
coinsurance for durable medical equipment (DME).
You have been asked to pay $160.63 for the back brace. 20% of $803.14 equals $160.63. A back brace falls
within the DME 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 a back brace
(L0648KX) provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 20, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code; the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical tray (A4550) provided December 11, 2019.
You asked the Plan to pay for the surgical tray. You say that enclosed you will find the medical records to justify the services medical necessity. You provided the services to the enrollee in good faith with the expectation of payment. The Plan denied your request. The Plan says the payment for this is included in the payment for the procedure. This item is not separately payable.
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 A4550 has a bundled relationship with the surgical procedure and cannot be paid as billed. 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 the surgical tray (A4550) provided December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis
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 procedure code L1820 is not supported.
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 L1820 is knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment. We find that CPT code L1820 is not supported in the medical record. Specifically, the documentation does not indicate that a knee orthosis was dispensed/fitted for the billed date of service. 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 knee orthosis
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2019 to the enrollee 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 October 30, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from November 19, 2019 to November 20, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you feel that you should owe a $0 copayment.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 $100 copayment for emergency care. You have been asked to pay a $100 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 for an ER visit provided from November 19, 2019 to November 20, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation and first intraoral periapical x-ray provided January 2, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation andfirst intraoral periapical x-ray. You say that you feel that more than just routine dental should be covered on your plan. You also say that you would like this bill to be taken care of with no responsibility on your part.The Plandenied your request. The Plan says these services are not covered benefits.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 inthis 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. Although routine oral examsand bitewing x-rays are covered under your plan, problem focused limited oral evaluationis not considered a routine oral examand first intraoral periapical x-ray is not considered a bitewing x-ray. Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation and firstintraoral periapical x-ray provided January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943) provided from October 28, 2019 to November 6, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these services are not covered by Medicare or the health plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services provided do not meet Medicare criteria for coverage of chiropractic services and are not covered under the Plan contract. Therefore, we decided that the Plan does not have to pay for the extra-spinal chiropractic manipulative treatment (98943) provided October 28, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physician services provided during an outpatient hospital stay on August 30, 2019. You asked the Plan to waive the copayments for physician services. You say that you disagree with the charges because you were being held under observation. 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 $10 copayment for physician/practitioner services, including doctor's office visits. You have been asked to pay the total copayment amount of $20 for physician services. Physician services fall 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 copayments for physician services provided during an outpatient hospital stay on August 30, 2019.