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

We decided that the Plan does not have to waive the coinsurance for the Botox injections provided from July 17, 2019 to October 16, 2019.
You asked the Plan to waive the coinsurance for the Botox injections. You say that you cannot afford the copayments for the medications that you need for your migraines. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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% of the cost for Part B covered chemotherapy drugs and other Part B covered drugs. You have been asked to pay $252.42 which is 20% of the allowed amount for the Botox injections on each date of service. The allowed amount is $1,262.10. ($1,262.10 x 20% = $252.42). ($252.42 + $252.42 = $504.84). The Botox injections fall 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 the Botox injections provided from July 17, 2019 to October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 25, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with medical records. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because the documentation
submitted does not include a valid physician order or laboratory requisition for the specific lab code billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 95861) provided on January 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code was not reported with a nerve conduction study.
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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas". 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 services. Our reviewer says that the use of CPT code 95861 is supported by the records provided. Our physician reviewer found that the enrollee underwent surgery on January 17, 2020, at which time intraoperative neuromonitoring was provided. The monitoring included bilateral, lower extremity, spontaneous EMG monitoring. As such, the documentation supports the billing of CPT code 95861. 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 services have been met. Therefore, we decided that the Plan has to pay for the services (CPT 95861) provided on January 17, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are 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. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the current acute care setting. Therefore, this request for LTACH services will be considered not medically necessary at this time.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forbone replacement graft for ridge preservation -per site (D7953) provided on April 9, 2018 and September 10, 2018 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plandenied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forbone replacement graft for ridge preservation -per site (D7953) provided on April 9, 2018 and September 10, 2018 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to a location that is more than 50 miles from your home address.
You asked the Plan to pre-approve the routine transportation trips exceeding 50 miles each way. You say that you are a cancer patient and need to schedule the spinal surgery or you will be permanently unable to walk again. The Plan denied your request. The Plan says the requested service is not a covered benefit according to the limitations outlined in the contract.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The records show that the location you are requesting transportation to is more than 50 miles from your home address. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation to a location that is more than 50 miles from your home address.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSkilled Nursing Facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says coverage criteria 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have a daily skilled nursing or therapy need. 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveSkilled Nursing Facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient surgery provided on December 10, 2019 to December 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON inpatient surgery. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The record shows that pre-authorization for these services was requested and denied. 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 inpatient surgery provided on December 10, 2019 to December 12, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on January 22, 2020.You asked the Plan to waive the copayment for a CT scan. You say that you were told this would be waived. The Plan denied your request. The Plan says the correct copayment has been applied.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 $125 copayment for outpatient diagnostic tests/advanced imaging services/freestanding radiological facility. You have been asked to pay a $125 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests/advanced imaging services/freestanding radiological facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675). You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe four core buildups, including any pins when required, two custom fabricated abutments, two abutment supported porcelain/ceramic crowns, eight crowns, and endodontic therapy provided on October 24, 2016.You asked the Plan to pay forthe core buildups, custom fabricated abutments, abutment supported crowns, crowns, and endodontic therapy. You say that you were not aware that you had dental insurance prior to this year.The Plan denied your request. The Plan says preventive dental services are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe four core buildups, including any pins when required, two custom fabricated abutments, two abutment supported porcelain/ceramic crowns, eight crowns, and endodontic therapy provided on October 24, 2016.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe circulating tumor cell (CTC) marker assay rendered on December 3, 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 the testing is not covered.The Plan must follow Medicare rules. The rules say that all CTC assays are non-covered.We looked at the file and Medicare rules. The services at issue are a CTC assay. This testing is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe circulating tumor cell (CTC) marker assay rendered on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on October 9, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you had preventive dental services in 2019 and paid out of pocket for them. The Plan denied your request. The Plan says periodontal maintenance is not included in your dental benefit, nor is it considered a preventative dental 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 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 periodontal maintenance provided on October 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit provided by a participating provider on January 23, 2020.
You asked the Plan to waive the copayment for an emergency department visit. You say that this was a scheduled EKG. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $90 copayment for outpatient hospital services/emergency room visit. You have been asked to pay a $90 copayment for an emergency department visit. An emergency department visit falls within the outpatient hospital services/emergency room visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency department visit provided a participating provider on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J3380) provided March 5 to April 30, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B Drugs. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the 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 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 injections (J3380) provided March 5 to April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray, and complete maxillary denture provided on March 16, 2020.
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, and complete maxillary denture. You say that you were under the impression that you had more coverage for dentures. The Plan denied your request. The Plan says the dollar maximum limit has been reached.
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 Plan offers a $1,000 maximum plan benefit per year. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the March 16, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, panoramic x-ray, and complete maxillary denture provided on March 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT angiography provided on April 2, 2020.You asked the Plan to waive the copayment for the CT angiography. You say that you were never billed a CT scan for this service in the past.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 $300 copayment for Medicare-covered diagnostic radiology services. You have been asked to pay a $300 copayment for the CT angiography. The CT angiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The CT angiography is considered a diagnostic radiology service. 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 CT angiography provided on April 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 23, 2020.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area orif the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 servicesat 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 physician's servicesprovided on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on January 17, 2020.You asked the Plan to waive the copayment forthese services. You say that the amount should be covered by Medicare.The Plan denied your request. The Plan says the copayment was applied correctlyThe 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 $350 copayment for outpatient surgery at an ambulatory surgical center. Review of the file shows that you received outpatient surgical services to your finger on January 17, 2020. You have been asked to pay a $350 copayment for these services. These services fall within the outpatient surgery at an ambulatory surgical center 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 copaymentforthe outpatient surgical services rendered on January 17, 2020.