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 October 8, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that 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 October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with suspension sleeve rendered on September 9, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a specified condition. We looked at the file and Medicare rules. The item at issue is a knee orthosis billed with code L1851. There is no documentation to support that the enrollee meets the criteria for coverage for these services. 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 with suspension sleeve rendered on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist physician services rendered to you on December 27, 2019.
You asked the Plan to waive the copayment for these services. You say that the provider told you that you would not be billed. The Plan denied your request. The Plan says the copayment was 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 $15 copayment for each specialist visit for Medicare-covered services.
Review of the file shows that you received specialist services on December 27, 2019. You have been asked to pay a $15 copayment for these services. These services fall within the specialist visit for Medicare-covered 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. The Plan cannot be held responsible for possible misinformation regarding your coverage given by a provider. Therefore, we decided that the Plan does not have to waive the copayment for the specialist physician services rendered to you on December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epidiolex for the enrollee.You asked the Plan to pre-approve this drug. You say that this has helped reduce the enrollee's seizure frequency.The Plan denied your request. The Plan says that this drug is not covered under the enrollee's Part B plan.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 Epidiolex for the enrollee.Benefits for this drug may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on January 29, 2020.You asked the Plan to pay for the crown. You say that before choosing this plan, you were told that crowns would be covered.The Plan denied your request. The Plan says this is not a covered service. The Plan also says that your spouse was informed of your coverage, that it covers restorative services including amalgam fillings and anterior composite resin fillings.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 crown provided on January 29, 2020.
Appeal type: Lab
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 November 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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
November 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 7, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says Medicare does not make separate payment for this service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and separate payment is not made for this service. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met.Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 5, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. 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 Medicare Part B prescription drugs. You received a Medicare Part B drug on December 5, 2019. The allowed amount is $1,138.29 and 20% of that is $227.66. You have been asked to pay the total coinsurance amount of $227.66 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of an Independence Drive interface kit, an IO module for R-Net based chairs and mount n mover mounting kit.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is a duplicate service.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a joystick. a joystick serves the same purpose as these services. Therefore, we decided that the Plan does not have to pre-approve the placement of an Independence Drive interface kit, an IO module for R-Net based chairs and mount n mover mounting kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on December 4, 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 services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the LSO is 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted documentation does not support that the LSO was medically necessary for the enrollee. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a timely physical examination of the back.
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 pay for the lumbar-sacral orthosis (LSO) rendered on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the an oxygen concentrator (E1390) provided on September 9, 2019. You asked the Plan to pay for the oxygen concentrator. You say that the oxygen equipment was medically necessary. The Plan denied your request. The Plan says the items were provided out-of-network. There were network providers available.
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 an oxygen concentrator (E1390) provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. You say that your pacemaker device should continue to be monitored by your cardiologist.The Plan denied your request. The Plan says the requested services are available within the enrollee's network.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for basic radiology services provided on December 11, 2019 and December 17, 2019.
You asked the Plan to waive the copayments for basic radiology services. You say that you disagree with the additional 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 $10 copayment for each basic imaging service. The medical records show that you received basic radiology services on December 11, 2019 and December 17, 2019. Therefore, you are responsible to pay a $10 copayment per each visit. The total amount you owe is: $20. You have been asked to pay the total copayment amount of $20 for basic radiology services. Basic radiology 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 copayments for basic radiology services provided on December 11, 2019 and December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling provided on December 19, 2019.
You asked the Plan to pay for the dental service. You say that the last manual of services that you received from the plan was for 2016. You say that fillings are listed as covered in that manual. You also say that you have not received an updated manual since and therefore the service should be covered. The Plan denied your request. The Plan says fillings are not a covered service.
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 filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and endodontic therapy provided by an OON provider on November 26, 2019 and December 10, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation and endodontic therapy. You say that the Plan told you that you had $1,000 available in annual benefits and that a root canal would be covered at 100%. The Plan denied your request. The Plan says the rendering provider is out-of-network. The Plan also says that the claim was paid correctly at the out-of-network level.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and endodontic therapy provided by an OON provider on November 26, 2019 and December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement crown - porcelain fused to high noble metal (D2750) on teeth 7 and 19.
You asked the Plan to pre-approve the dental services. You say that you are appealing the decision to deny the two crown teeth that was requested by your dentist. The crowns were places in 1980 and you feel sensitive with pain and discomfort when you consume food. The Plan denied your request. The Plan says this request is not reasonable or necessary and does not meet the coverage criteria. There are other treatments which may be medically appropriate or 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 the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found due to the lack of documentation of recurrent caries or significant breakdown of the restorations in place on teeth #'s 7 and 19, the criteria for coverage for replacement crowns (D2750) has not been met. The record also indicates that tooth #19 contains a retainer for a Maryland Bridge (resin bonded bridge) replacing tooth #20 with an open margin on the disto-buccal aspect. There was no indication that the retainer was loose. A repair of the defect is the recommended treatment at this time. 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 replacement crown - porcelain fused to high noble metal (D2750) on teeth 7 and 19.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99284) provided November 6, 2019.
You asked the Plan to pay for the physician services. You say that services were medically necessary and properly billed. The Plan denied your request. The Plan says the number of units billed were exceeded.
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 99284 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99284) provided November 6, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injection, 32 mg, every 28 days.
You asked the Plan to pre-approve the Zilretta injection. You say that the enrollee has tried and failed Kenalog and corticoid steroids. The Plan denied your request. The Plan says Zilretta is not medically necessary. The Plan says you have not stated why the step therapy drug would not be as effective for the enrollee as the requested drug, or would have adverse effects for the enrollee.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Zilretta injection. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the record does not show that the enrollee trialed and failed the required drug, Kenalog. The reviewer also found that the documentation does not support that Kenalog (Triamcinolone acetonide) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Zilretta injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta injection, 32 mg, every 28 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is not a covered benefit.
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 pre-approve the crown.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 2, 2019 to September 9, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim must be billed with a valid Health Insurance Prospective Payment System (HIPPS) code, correct type of bill code, and a valid 5 digit Computer Based Statistical Area (CBSA) code. The claims were not billed with these specific items. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 2, 2019 to September 9, 2019.