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

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 28, 2018.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on December 28, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on September 5,
2019.
You asked the Plan to waive the coinsurance for the back brace. You say that you were misdiagnosed and
should not owe this. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for Medicare-covered items.
You have been asked to pay $188.64, which is 20% of the allowed amount for the back brace. The allowed
amount is $943.21 (20% x $943.21 = $188.64). The back brace falls within the "Durable medical equipment
(DME) and related supplies" 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 back
brace provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64454) provided July 7, 2020.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan
denied your request. The Plan says the number of units billed exceeds the allowable amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 64454 is 2. You billed 3 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore,
we decided that the Plan does not have to pay for injections (64454) provided July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 7,
2020.
You asked the Plan to waive the copayment for laboratory services. You say that you do not understand why
the Plan did not pay anything. 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 $45
copayment for lab services provided at an outpatient hospital facility.
You have been asked to pay the allowed amount of $40.17, which is less than the $45 copayment for laboratory
services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies
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 laboratory services provided on
August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Vitamin D screeningprovided on May 29, 2020.You asked the Plan to pay forVitamin D; 25 hydroxy, includes fraction(s), if performed (82306). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the vitamin assay panel is a screening procedure and therefore non-covered.The Plan follows Medicare rules. The rules explicitly say that screening laboratory testsare not covered.The test at issue in this appeal, Vitamin D; 25 hydroxy, includes fraction(s), if performed (82306), was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe Vitamin D screeningprovided on May 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 9, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be sent to Original Medicare.
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 physician services provided to the enrollee on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on July 28, 2020.
You asked the Plan to pay for services not related to manual manipulation of the spine. You say that these
services should be covered by the Plan. The Plan denied your request. The Plan says you have exhausted the
number of visits allowed by your Plan contract.
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 Plan contract says that 6 visits are covered per
year. The records show that you had exhausted the number of visits allowed. Therefore, we decided that the
Plan does not have to pay for chiropractic services provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from July 7, 2020, to August 10, 2020.
You asked the Plan to pay for those services not related to manual manipulation of the spine. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says traction, therapy, cold/hot pack applications, electrical stimulation and x-rays are not covered when provided by a chiropractor.
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 at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from July 7, 2020, to August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on July 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for non-emergent wound care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by an in-network 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 wound care provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 30, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on July 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 2,
2020, to July 14, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the admission was
necessary due to the enrollee's lab results. The Plan denied your request. The Plan says the claims were
processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $390 copayment for days 1-5 for inpatient hospital care.
The enrollee had an inpatient hospital stay from July 2, 2020, to July 14, 2020. Therefore, the enrollee is
responsible to pay the total allowed amount of $1,810.17.
The enrollee has been asked to pay $1,810.17 for an inpatient hospital stay. An inpatient hospital stay falls
within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for an inpatient hospital stay from July 2, 2020, to July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Ranibizumab injection (J2778) provided on April 17, 2020.You asked the Plan to waive the coinsurance forthe Ranibizumab injection. You say that you disagree with the coinsurance that is being charged.The Plan denied your request. The Plan says the coinsurance applied correctly in this case.The rules say a plan must disclose to its enrollees in clear, accurate termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B drugs. You have been asked to pay a total cost share of $347.28 ($1736.40 allowed amount x 20% = $347.28) for the Ranibizumab injection. The service provided falls within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 forthe Ranibizumab injection (J2778) provided on April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the 4 alveoplasty not in conjunction with
extractions (D7320) provided on March 18, 2020.
You asked the Plan to pay the full amount for the dental services. You say that you were advised that the
service would be covered. You say that you do not have the money to pay for this bill. You also say that they
have not finished your teeth. The Plan denied your request. The Plan says you have an annual maximum of
$3,500. The Plan says that the annual maximum benefit has been exhausted.
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 annual maximum of $3,500 has
been exhausted. The record shows that the Plan paid $3,479 for dental services that you received on February
18, 2020, and $21 for the dental services that you on March 18, 2020, thus exhausting your benefit. Therefore,
we decided that the Plan does not have to pay more for the 4 alveoplasty not in conjunction with extractions
(D7320) provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transit securement assembly.You asked the Plan to pre-approvea transit securement assembly. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says an accessory used to secure the wheelchair during transportation outside of the home is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea transit securement assembly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), first
intraoral periapical x-ray (D0220) three additional intraoral periapical x-rays (D0230 x3), and mandibular
partial denture (D5214) provided on February 28, 2020, and July 24, 2020.
You asked the Plan to pay for the topical application of fluoride varnish, intraoral periapical x-rays, and
mandibular partial denture. You say that you requested additional dental coverage to be included, and you
confirmed that there would be additional coverage for the charge of $21 per month. The Plan denied your
request. The Plan says these services are not covered under your mandatory dental supplemental benefit. The
Plan also confirmed that you did not elect to enroll in the optional supplemental benefit package.
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. The records show that the Plan confirmed that you did not contact the
Plan prior to receiving these services to add the optional supplemental benefit to your plan. The Plan also
confirmed that you have not paid $21 per month for the optional supplemental benefit. Therefore, we decided
that the Plan does not have to pay for the topical application of fluoride varnish (D1206), first intraoral
periapical x-ray (D0220) three additional intraoral periapical x-rays (D0230 x3), and mandibular partial denture
(D5214) provided on February 28, 2020, and July 24, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay fora computed tomography (CT) scan (74150) provided on June 29, 2020.You asked the Plan to pay fora CT scan. You say that this claim is not a duplicate.The Plan denied your request. The Plan says that this claim was previously billed and paid.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 states that the documentation supports one unit of this code, which was previously billed and paid. However, the case file does not included documentation showing that this was previously billed and paid, such as a claim form or remittance advice. Without this documentation, it cannot be verified that this service was previously paid.Therefore, we decided that the Plan has to pay fora computed tomography (CT) scan (74150) provided on June 29, 2020.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthisis not covered as the height adjustment feature is a convenience feature.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance tablets.
You asked the Plan to pre-approve Jardiance tablets. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Jardiance tablets are not covered under the enrollee's
Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95861, 95938, 95939, 95955) provided on March 9, 2020.

You asked the Plan to pay for neuromonitoring services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not billed with a required modifier.

The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. . Specifically, these services have both a professional and technical component. This means that modifiers should be used with these codes as the technical component is paid to the hospital. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95861, 95938, 95939, 95955) provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pre-approve acute  inpatient  rehabilitation  facility  (IRF)  admission and services.

You asked the  Plan to pre-approve IRF care. You  say that you  need  to go to rehab  to get  your  strength  back.The  Plan  denied  your  request.  The Plan  says that  your  needs may  be met  at a different  level  of 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.  You do not require  the intensity  of  services  provided  at an IRF. Specifically,  you  are not shown  to require  fifteen hours  per week of rehabilitative  services  and regular  physician  evaluation.  Your  care needs  can be met  at a lower  level  of care. Our physician  reviewer  found  that  your  condition  does not  meet  Medicare  criteria  for IRF 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 IRF care have  not  been met.Therefore,  we decided that  the  Plan  does not have to pre-approve acute  inpatient  rehabilitation  facility  (IRF)  admission  and service
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic imaging, tonometry exam and ophthalmic ultrasound provided on July 9, 2020.
You asked the Plan to waive the copayment for the ophthalmic imaging, tonometry exam and ophthalmic ultrasound. You say that there shouldn't have been so many tests done. You say that you are being billed incorrectly. 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 $50 copayment for diagnostic radiology and a $50 copayment for all other diagnostic procedures and tests. Separate office visit copay applies for diagnostic tests and procedures, diagnostic radiology, and therapeutic radiology. You have been asked to pay a $50 copayment for the ophthalmic imaging and tonometry exam and a $50 copayment for the ophthalmic ultrasound. The ophthalmic imaging, tonometry exam and ophthalmic ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 ophthalmic imaging, tonometry exam and ophthalmic ultrasound provided on July 9, 2020.