Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed Tomography (CT) of the neck (70491) provided on June 14, 2019. You asked the Plan to pay for the CT scan. You say that services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers who could render the service at issue. 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 Computed Tomography (CT) of the neck (70491) provided on June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a treadmill provided on October 14, 2019.
You asked the Plan to pay for the treadmill. You say that the treadmill is medically necessary. The Plan denied
your request. The Plan says the treadmill is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for a treadmill provided on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay on October 31, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges because you did not stay the night.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 $195 copayment each day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay on October 31, 2019. Therefore, you are responsible to pay the $195 copayment. You have been asked to pay a $195 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 foran inpatient hospital stay on October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ferric carboxymaltose injection provided on October 17, 2019 and October 24 2019.You asked the Plan to waive the coinsurance forthe ferric carboxymaltose injection. You say that the injections have always been paid for. You say that you don't want to pay the bill.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B drugs from an in-network provider.The enrollee has beenasked to pay a total of $222.72 for the ferric carboxymaltose injections. The ferric carboxymaltose injections fall within the "Medicare Part B prescription drugs" 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 coinsurance forthe ferric carboxymaltose injection provided on October 17, 2019 and October 24 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for natriuretic peptide lab services provided to on July 19, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says BNP for monitoring stable CHF is not a covered service. The Plan follows Medicare rules. Medicare rules say that B-type Natriuretic Peptide (BNP) Testing is only covered under certain medical indications.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 lab services. Our physician reviewer found that the enrolleeis described as having stable congestive heart failure. The documentation reports no dyspnea, normal cardiac and respiratory exams,and normal room air oxygenation. In this circumstance,the documentation provided does not support the medical necessity for the testing at issue. Coverage criteria are not met since there are no documented covered indications for the test.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 lab services have not been met.Therefore, we decided that the Plan does not have to pay fornatriuretic peptide lab services provided on July 19,2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the chest.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted documentation does not support that the CTA is indicated. There are no medical records to support that the CTA of the chest would be reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) scan of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Nursing Facility Care (99308) provided on November 25, 2019.You asked the Plan to pay forthe nursing facility care. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-authorized or emergent. 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 forthe Nursing Facility Care (99308) provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure machine.
You asked the Plan to pre-approve the automatic blood pressure machine. You say that irregularities were
found on your EKG. You say that you need to check your blood pressure twice a day to monitor whether
systolic is above 100. The Plan denied your request. The Plan says there is no documented suspicion of white
coat hypertension or of suspected masked hypertension. The Plan says that there is no documentation of
unusual or significantly labile blood pressure/heart rate to warrant coverage of the requested device.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure machine.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay fora crown (D2740) for tooth # 14 provided on April 4, 2019.You asked the Plan to pay forthe dental service. You say that the enrollee's tooth had 2 separate large existing occlusal and lingual alloy fillings with fractures across the mesial portion of the tooth. You say that the tooth was symptomatic prior to the treatment due to biting pressure on the fracture lines. You also say that the crown was the only way to adequately resolve the enrollee's pain while providing full coverage protection for the tooth.The Plan denied your request. The Plan says that the documentation does not shows extensive decay or fracture of tooth # 14. The Plan also says that the crown is not medically 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 service 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 pay for the dental service. Our reviewer says that the service is medically necessary. Our physician reviewer found the documentation of symptoms of a cracked tooth # 14 meet the criteria for coverage for a crown to restore the tooth to proper masticatory function and to prevent complete fracture of the coronal structure.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 service have been met.Therefore, we decided that the Plan has to pay fora crown (D2740) for tooth # 14 provided on April 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe spinal tap procedure provided on November 21, 2019.You asked the Plan to waive the copayment forthe spinal tap procedure. You say that you should not be responsible for this amount. The Plan denied your request. The Plan says the deductible amount was removed and the claim will only reflect the copayment 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 $150 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $125 copayment for the spinal tap procedure. The spinal tap procedurefalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forthe spinal tap procedure provided on November 21, 2019.Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the member liability of the claim. Please contact the health plan to receive a corrected Explanation of Benefits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for post cataract laser surgery provided by on December 13, 2019.You asked the Plan to pay for the post cataract laser surgery. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be providedwith 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 post cataract laser surgery provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the co-insurance for a filling (D2740) provided April 13 to May 16, 2019.
You asked the Plan to waive the co-insurance for the filling. You say that the co-insurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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. We looked at the file and Medicare rules. The contract stipulates a 55% co-insurance on fillings. Therefore, we decided that the Plan does not have to waive the co-insurance for a filling (D2740) provided April 13 to May 16, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the testing provided to the enrollee on September 12, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that code 81528 is not a payable code.
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 81528 is supported. Specifically, the rules show that payment is allowed under the clinical lab fee schedule. The records provided indicate the services at issue were performed and billed by a lab. The Plan has not made reasonable and diligent efforts to forward to us information regarding their decision to deny the code at issue. Based on this information, we decided that Medicare rules for coverage of the testing have been met. Therefore, we decided that the Plan has to pay for the testing provided to the enrollee on September 12, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete upper denture and complete lower denture provided July 3, 2019.
You asked the Plan to pay for the dental services. You say that you did not realize that the enrollee had dental benefits until after you have exhausted your bank account in an effort to purchase his much needed dentures. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider. The plan says that non-emergent services require prior-authorization prior to services being rendered.
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 health plan contract says services obtained from vendors outside the network are not covered. 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 complete upper denture and complete lower denture provided July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that authorization was requested by your primary care physician.The Plan denied your request. The Plan says the services were not urgent and were rendered without 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 has network providers available who can provide the items/services at issue inthis 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 medical services provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment on tooth #27 for the
enrollee.
You asked the Plan to pre-approve these services. You say that the member currently has dentures which are
causing sores in her mouth. The Plan denied your request. The Plan says that the member has fully exhausted
the comprehensive dental allowance.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. The Plan coverage rules apply in this case. The Plan covers up to a $2,600 allowance for
comprehensive dental services every year.
We looked at the file and Medicare rules. The file shows that the plan has already approved the maximum
yearly benefit of $2,600 for dental services. There is no provision in the contract which would require the plan
to approve more than this amount. Therefore, we decided that the Plan does not have to pre-approve a custom
fabricated abutment on tooth #27 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November 5, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work is a part of your annual wellness visit. 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 a $20 copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film x-rays, and ultrasounds. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is a separate 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 laboratory work provided on November 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home health aide visits.You asked the Plan to pre-approvethe additional services. The Plan denied your request. The Plan says authorization needs to be requested every 30 days.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 additional services. Our physician reviewer found that you are performing essential activities of daily living without hands-on assistance, but are ambulatingless than household distances. Home health aide services were continued in support of your skilled needs, and would include assistance with activities of daily living and in performing her maintenance home exercise program. There is no identified ongoing skilled nursing or physical therapy need. You had caregiver assistance available in terms of maintaining your home exercise program and for instrumental activities of daily living. When Home Health Aide services are requested and are not in support of a skilled need, the service is not considered medically reasonable or necessary.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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve7 additional home health aide visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on September 23, 2019.Youasked the Plan to pay forthe unlisted neurological or neuromuscular diagnostic procedure. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that train of four testing was performed. This service is considered a bundled procedure and the payment for it is included in the payment for the already approved and paid neuromonitoring. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on September 23, 2019.