Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator purchased on August 23,
2019.
You asked the Plan to pay for the portable oxygen concentrator. The Plan denied your request. The Plan says
that this is only covered for rental.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily noncovered.
Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator
purchased on August 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided November 29 to December 28, 2019.
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there was no daily skilled nursing or therapy needs. The enrollee's needs could be met at 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided November 29 to December 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on January 23, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you disagree with the amount owed.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 specialist's office visits. Review of the file shows that the specialist's office visit copayment requirement is $40. However, the allowed amount for this service was $38. Since this is less than your copayment requirement, you were charged the lesser amount. You have been asked to pay a $38 copayment for the office visit. the office visit falls within the physician/practitioner services 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, wedecided that the Plan does not have to waive the copayment forthe office visit provided on January 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for the diagnostic mammogram, tomosynthesis and ultrasound provided on January 24, 2020.
You asked the Plan to reduce the deductible for the diagnostic mammogram, tomosynthesis and ultrasound. You say that your physician requested the tests. You say that the cost should be reduced to $100. The Plan denied your request. The Plan says the deductible 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 in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Until you have paid the in-network deductible amount, you must pay the full cost of your covered in-network services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 in-network deductible applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram, tomosynthesis and ultrasound were received on January 24, 2020. Therefore, we decided that the Plan does not have to reduce the deductible for the diagnostic mammogram, tomosynthesis and ultrasound provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services provided by a non-Medicare qualified mental health professional from August 21, 2019 to September 4, 2019.You asked the Plan to pay forthe psychotherapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that psychotherapy services are only covered when provided by a Medicare qualified mental health care professional.We looked at the file and Medicare rules. The provider of these services was not a Medicare qualified mental health care professional for the dates of service. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe psychotherapy services provided by a non-Medicare qualified mental health professional from August 21, 2019 to September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 11, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this appeal reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab tests provided on November 11, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 8, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 18, 2019.
You asked the Plan to pay for the services provided. You say that the codes are supported by the physician's
custom profile. The Plan denied your request. The Plan says there is no evidence of a relationship with the
enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician
who is treating the beneficiary.
We looked at the file and Medicare rules. There were insufficient records to show that the physician is treating
the enrollee for a specific medical problem, and use the results in the management of a specific medical
problem. Based on this information, we decided that Medicare rules for coverage of the services provided have
not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided
on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three topical applications of fluoride varnish (D1206 x3)
and two sets of bitewings (D0274 x2) provided on May 28, 2019 and December 3, 2019.
You asked the Plan to pay for the topical applications of fluoride varnish and two sets of bitewings. You say
that you contacted the Plan prior to having the services rendered and were told that the treating provider is innetwork.
You also say that you went for regular exams and cleanings. The Plan denied your request. The Plan
says these services are not covered by your plan.
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 three
topical applications of fluoride varnish (D1206 x3) and two sets of bitewings (D0274 x2) provided on May 28,
2019 and December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face down positioning table and delivery fee provided on
August 13, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this is not
covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that this device is precautionary in nature and does
not fall into a covered benefit category.
Although this device may have been appropriate, no Medicare coverage exists for such an item. Therefore, we
decided that the Plan does not have to pay for the face down positioning table and delivery fee provided on
August 13, 2019.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for the destruction by neurolytic agent. We decided that the Plan does not have to reduce the cost-sharing charges for Medicare Part B drugs and the destruction by neurolytic agent to the amount you requested. You asked the Plan to reduce the cost-sharing charges for Medicare Part B drugs and the destruction by neurolytic agent. You say that you should only owe a specialist copayment.The Plan says that the claims were processed correctly and you are being charged the correct amount.We decided that the Plan has to reduce the cost-sharing charges forthe destruction by neurolytic agent from the total amount of $196.30 to $45. The health plan contract says that you must pay a $45 copayment for specialist services. The destruction by neurolytic agent is considered a surgical procedure. Therefore, you cannot be asked to pay more than a $45 copayment for the destruction by neurolytic agent.Therefore, we decided that the Plan has to reduce the cost-sharing charges for the destruction by neurolytic agent from $196.30 to $45. We also decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs. 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 Medicare Part B drugs.The total allowed amount for Medicare Part B drugs is $9.71 and 20% of that is $1.94. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95913) and needle electromyography (95886) provided on October 11, 2019.
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these codes should be paid. The Plan denied your request. The Plan says there is more appropriate code that should be used for the procedure performed.
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 95913 is nerve conduction studies; 13 or more studies and 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 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 nerve conduction studies and needle electromyography. Our reviewer says that the documentation does not support these codes. Our physician reviewer found the submitted medical records show that nerve conduction studies were conducted on nine nerves, not thirteen, therefore, code 95913 is not supported. Although the records show that needle electromyography testing of the bilateral upper extremities was performed in conjunction with nerve conduction studies, code 95886 is not supported because it is an add-on code that cannot be paid when the primary procedure is denied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95913) and needle electromyography (95886) provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options (K0861). You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options (K0861). You say that the requested group 3 power wheelchair with multiple power options (K0861) is medically necessary. The Plan denied your request. The Plan says that the requested group 3 power wheelchair with multiple power options (K0861) does not meet criteria. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's rationale for denial of a group 3 power wheelchair with multiple power options (K0861) is the enrollee not meeting the medical need per Medicare criteria. However, the file does not show that the Plan provided or requested relevant medical records from the enrollee's treating providers. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve a group 3 power wheelchair with multiple power options (K0861).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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on December 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on December 18, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises provided on December 30, 2019.You asked the Plan to pay for the therapeutic exercises. You say that this claim is not related to the enrollee's time in hospice.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 enrollee'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 the therapeutic exercises provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and strapping services provided on December 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when received by an OON 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 for the office visit and strapping services provided on December 12, 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 hearing aid services.
You asked the Plan to pre-approve hearing aid services. The Plan denied your request. The Plan says that this is not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aid services may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aid services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 15, 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 procedure code 29827 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 29827-22-LT is arthroscopy, shoulder, surgical; with rotator cuff repair.We find that CPT code 29827-22-LT is not supported in the medical record. Specifically, the operative report does not include documentation of a left surgical shoulder arthroscopy with rotator cuff repair. 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 surgical services rendered on November 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown on tooth #30 (D2740).You asked the Plan to pre-approve a crown on tooth #30. You say that the requested service is necessary.The Plan denied your request.The Plan says based on the documentation provided, coverage criteria has not been met. 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 a crown when certain criteria is 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 a crown on tooth #30. Our reviewer says that the service is not medically necessary. Our physician reviewer found the low quality x-ray provided does show some prior restoration to the tooth, however it does not appear to involve extensive breakdown to the tooth. The Plan criteria provides that in order to consider a crown restoration, there must be pathologic destruction to the tooth by caries or trauma involving four or more surfaces and/or at least two cusps. In this instance there has been no showing of significant structural breakdown such that a full coverage crown restoration is deemed 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 a crown on tooth #30 have not been met.Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #30 (D2740).