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

We decided that the Plan does not have to pay for an office visit (G0439) provided on March 22, 2019.
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your request. The Plan says this claim needs to be processed by your primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed your provider to submit the claim to your primary insurance. As the secondary insurer, the Plan cannot be held responsible for an office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an office visit (G0439) provided on March 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional crown provided on October 8, 2019.You asked the Plan to pay for the provisional crown. You say that you do not feel payment for the temporary crown is your responsibility. You also say that this service is one step in the overall covered procedure even though it was billed separately.The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that your dental benefits only cover permanent crowns or bridges.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 provisional crown provided on October 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Duplex Scan (93970) provided June 29, 2018.You asked the Plan to pay forthe duplex scan. You say that the services were medically necessary and billed correctly.The Plan denied your request. The Plan says the claim submitted was an exact duplicate of a previous claim.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 93970 is not supported in the medical record. Specifically, the claim submitted was an exact duplicate of claim 820181840013418 which has already been allowed. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met.Therefore, we decided that the Plan does not have to pay fora Duplex Scan (93970) provided June 29, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea motorized wheelchair.You asked the Planto pre-approvethe power wheelchair. You say that you are not able to travel outside of the home without a power wheelchair.The Plandenied your request. The Plansaysthere is no documentation that this wheelchair is needed to help with MRADLs within the home. Equipment primarily needed for use outside the home is not covered by Medicare.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. Mobility equipment must be needed for assistance with completion of MRADLs in 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 Plandoes not haveto pre-approvea motorized wheelchair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on October 16, 2018.You asked the Plan to waive the copay for the ambulance transport. You say that this should be waived because of special circumstances.The Plan denied your request. The Plan says that you are responsible for the associated cost share.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 $25 copay for each Medicare-covered one-way ambulance trip. You have been asked to pay a $25 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way ambulance trip 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 copay forthe ambulance transport provided on October 16, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that the enrollee is immobile and needs the supplies.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services for the enrollee.
You asked the Plan to pre-approve continued services. You say that the enrollee has a lack of mobility, and ability to self-care. The Plan denied your request. The Plan says the enrollee has reached the 100-day limitation.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from October 7, 2019 to January 15, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from August 26, 2019 through August 28, 2019.You asked the Plan to pay for the services. You say that your physicians are hospital based and our providers rely on the facility to obtain the proper authorization.The Plan denied your request. The Plan says no authorization was found for this date of 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 to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The physician is a non-contracted provider. With the information we have, we cannot determine how the member came to the servicing provider, or whether the services are medically necessary. 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 services provided to the enrollee from August 26, 2019 through August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (prostate) gene expression profile provided on August 27, 2019.
You asked the Plan to pay for the oncology (prostate) gene expression profile. 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 service 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 oncology (prostate) gene expression profile provided on August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from September 3,2019 through September 8, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you did not know you had to pay the cost-share.The Plandenied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file shows that you were admitted on September 3, 2019 and discharged on September 8, 2019. You were asked to pay a $395 copayment per day from September 3, 2019 through September 6, 2019, days 1-4 of your inpatient stay. There were nocopayment charges from September 7, 2019, day 5 of your inpatient hospital care until your day of discharge September 8, 2019. Per your contract there is a $395 copayment per day required for days 1-4. 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 forinpatient hospital care from September 3, 2019 through September 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy, 30 minutes, provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient therapy services. You say that you have been seeing this provider for many years. You say that you trust him and his knowledge of your medication and diagnosis. You also say that you do not want to start treatment with a new doctor. The Plan denied your request. The Plan says authorization was not obtained before you received the services. The Plan says the services are available in network. The Plan also says that the services were not urgent or emergent.
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 psychotherapy, 30 minutes, provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (J7325).
You asked the Plan to pre-approve Synvisc injections. You say that the medication is necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Synvisc injections (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physician services (69209) provided on June 10, 2019 and September 18, 2019.You asked the Plan to waive the copayments forthe physician services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received additional services beyond your wellness visit on June 10, 2019. The Plan states no cost share applied for the annual wellness portion of your visit. The Plan states you received ear wax removal, which is beyond the scope of an annual wellness visit. The Plan states the correct copayment has applied for the June 10, 2019 date of service and the September 18, 2019 date of service.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. We looked at the file, the Plan contract and Medicare rules. The file showsthat you received ear was removal services (CPT code 69209) on June 10, 2019 and on September 18, 2019. This service goes beyond the scope of your annual wellness visit provided to you on June 10, 2019. The file shows no cost share was applied to your annual wellness visit. Additionally, your visit on September 18, 2019 is considered a separate visit with your primary care physician that applies a separate copayment. You have been asked to pay a $10 copayment for each visit with your primary care physicianfor ear wax removal (69209), totaling $20. These physician services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing isa 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 forthe physician services (69209) provided on June 10, 2019 and September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve  a cervical traction device, with inflatable air bladder(s).You asked the Plan to pre-approvea cervical traction device (E0856). You say that you suffer from a neck condition and want to try the traction cervical collar to see if surgery is not required.The Plan denied your request. The Plan says the requested cervical traction device is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The cervical traction device is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a cervical traction device (E0856) have not been met.Therefore, we decided that the Plan does not have to pre-approvea cervical traction device, with inflatable air bladder(s).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 3, 2019.You asked the Plan to pay for the laboratory services. 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 laboratory services provided on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient services provided from February 16, 2019 to February22, 2019.You asked the Plan to pay forinpatient services. You say that E43 is clinically valid as a secondary diagnosis for this admission. The diagnosis was correctly billed and should be reconsidered.The Plan denied your request. The Plan says that the secondary diagnosis code E43 (unspecified severe protein-calorie malnutrition) is not supported by the medical records.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. Specifically, the Plan denied your request stating that secondary diagnosis code E43 (unspecified severe protein-calorie malnutrition) is not supported by the medical records. The file did not contain medical records to corroborate the Plan's denial rationale. Without the medical records, we cannot perform a review to see if E43 is supported as billed. It is the burden of the Medicare Health Plan to substantiate the denial with medical evidence. The denial is not substantiated and wemust find in your favor.Therefore, we decided that the Plan has to pay forinpatient services provided from February 16, 2019 to February 22, 2019.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on September 23, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received due to the quality of care. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received inpatient hospital care provided on September 23, 2019. You are asked to pay a $300 copayment for the inpatient hospital care. 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 inpatient hospital care provided on September 23, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveCTA of the chest for the enrollee.You asked the Plan to pre-approvethe scan. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable or necessary. Our physician reviewer found the documentation supports the medical necessity of the study in question. The patient hasa known AAA. Therefore the enrollee's risk of having a co-existing thoracic aortic aneurysm is significant. The absence of symptoms has no bearing on this risk. The thoracic aorta cannot be adequately visualized with a screening tool such as ultrasound. It is medically necessary and reasonable to obtain a chest CT in the setting of AAA.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 scan have been met.Therefore, we decided that the Plan has to pre-approveCTA of the chest for the enrollee.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria for SNF care has not been 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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital the
enrollee did not require any skilled nursing or rehab services on a daily basis. The enrollee was not expected to
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent
deterioration with mobility or activities of daily living (ADLs). The enrollee does not require skilled therapy to
establish a safe and effective maintenance program. As a practical matter, the enrollee does not require any
skilled services on an inpatient basis, at a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.