Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture for the enrollee.
You asked the Plan to pre-approve the denture. You say that this is medically necessary. The Plan denied your
request. The Plan says this 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 a
complete mandibular denture for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBelbuca (J3490).You asked the Plan to pre-approveBelbuca. 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. 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-approveBelbuca (J3490).Benefits for Belbucamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network gastroenterologist.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says one visit is approved, further services are available from network providers.Medicare rules say that planscan 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network gastroenterologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment (L1833 and L2397) provided on August 7, 2020.You asked the Plan to pay forthe durable medical equipment. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order.Therefore, we decided that the Plan does not have to pay forthe durablemedical equipment (L1833 and L2397) provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering assisted living facility is also out-of-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 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 physician services provided on September 21, 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 two bone replacement grafts for ridge preservation
(D7953 x2), two placements of intra-socket biological dressings (D7922 x2), and local anesthesia (D9215).

You asked the Plan to pre-approve the bone replacement grafts, placements of intra-socket biological dressings,
and local anesthesia. You say that you cannot afford to pay out of pocket for these procedures. The Plan denied
your request. The Plan says these services are not covered under your benefit package.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested i tems or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two
bone replacement grafts for ridge preservation (D7953 x2), two placements of intra-socket biological dressings
(D7922 x2), and local anesthesia (D9215).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on June 1, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on June 1,2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on July 17, 2020.You asked the Planto waive the copayment for an ultrasound. You say that you do not think you should have to pay for each of these. 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services/in-network. You have been asked to pay a $110 copayment for each ultrasound that is provided. The total amount you are being asked to pay $330 ($110 x 3 ultrasounds = $330). Since three ultrasounds were provided,the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services/in-network 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 ultrasound provided by a participating provider on July 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous image-guided lumbar decompression (PILD).You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PILD is covered when specific criteria are met.We asked our physician reviewer tocarefully 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 enrollee has a diagnosis of spinal stenosis. The records do not show that the enrollee is part of a approved clinical study, as required by the Medicare rules. The PILD procedure is therefore not reasonable or 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-approvepercutaneous image-guided lumbar decompression (PILD).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee shows the endurance needed for acute rehab supported by physician assessments. The Plan denied your request. The Plan says the enrollee can be equally served at an alternative level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for conservative management of a sacral fracture. Her medical conditions are stable. The complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora specialist visit, an X-ray and an ultrasound provided from August 7, 2020, to August 18, 2020.You asked the Plan towaive the copayments fora specialist visit, an X-ray and an ultrasound. You say that you thought that all copayments would be waived.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 $35 copayment for specialist visits. Your contr.You received a specialist visit on August 7, 2020. Therefore, you are responsible to pay the $35 copayment. You received an X-ray on August 7, 2020. Therefore, you are responsible to pay the $10 copayment. You received an ultrasound on August 18, 2020. Therefore, you are responsible to pay the $10 copayment. The total amount you owe is: $55.  You have been asked to pay the total copayment amount of $55 for a specialist visit, an X-ray and an ultrasound. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An X-ray and an ultrasound fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments fora specialist visit, an X-ray and an ultrasound provided from August 7, 2020, to August 18, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy provided on August 13, 2020.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that you didn't realize the colonoscopy would be classified as diagnostic resulting in a high copayment. You say that this should be classified as a regular screening.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 $550 copayment for each visit to an outpatient hospital facility for Medicare-covered services.You have been asked to pay a $550 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the colonoscopy was ordered for diagnostic services. 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 forthe diagnostic colonoscopy provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visits (99214) provided on September 3, 2019, and November 21, 2019.
You asked the Plan to waive the copayment for office visits. You say that these visits should be covered. The Plan denied your request. The Plan says these visits processed 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 $5 copayment for primary care physician services. You have been asked to pay a $5 copayment for each office visit. These office visits were primary care physician services. 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 office visits (99214) provided on September 3, 2019, and November 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided July 7, 2020
to August 5, 2020.
You asked the Plan to pay for the SNF services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the enrollee's SNF benefit was exhausted at the time services were rendered.
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 January 6, 2020
to July 3, 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 pay for skilled nursing facility (SNF) services provided July 7, 2020 to August 5,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on August 10, 2020.
You asked the Plan to waive the copayment for the laboratory 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 laboratory services on the date of service at issue in this appeal. The
Plan says that the correct copayment has applied per your contract with the Plan.
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 day, per provider, for Medicare-covered lab services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received laboratory
services on August 10, 2020. You have been asked to pay a $20 copayment for the laboratory services. The
laboratory services fall within the Outpatient diagnostic tests benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the laboratory services provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on July 23, 2020.
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the orthoses provided on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L0650, L1851, L2397) provided on May 8, 2020.
You asked the Plan to pay for orthotics. You say that these items are supported by the records. The Plan denied your request. The Plan says there is not a valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The itemized packing slip does not include the carrier's tracking number, therefore delivery cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthotics (L0650, L1851, L2397) provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe denosumab injection provided on May 27, 2020.You asked the Plan to waive the coinsurance forthe denosumab injection. You say that the charges should be reimbursed.The Plan denied your request. The Plan says the$25 copayment for the office visit will be applied toward thecoinsurance.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 each Medicare-covered Part B drug.You have been asked to pay $231.36, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,156.80 (20% x $1,156.80 = $231.36). The denosumab injection falls within the "Medicare Part B Prescription Drugs" benefit category. This means that you have been asked to paythe 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 forthe denosumab injection provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the urgent care visit provided on October 1, 2020.
You asked the Plan to waive the urgent care visit. You say that you should not be responsible for the $50 copayment. 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 $50 copayment for each urgent care visit. You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" 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 urgent care visit provided on October 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on July 6, 2020.You asked the Plan to pay forthe ambulance services. You say that this was a lift assistance.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by you on July 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from October 24, 2018, to December 22, 2018.
You asked the Plan to pay for the home health services. You say that you have submitted a corrected claim with a valid HIPPS code. The Plan denied your request. The Plan says the HIPPS code billed is not valid as it indicates that non-routine supplies were provided which are not billed elsewhere on the claim.
The Plan must follow Medicare rules. Medicare rules say that home health claims must have a line with revenue code 0023 with the first four digits of the HIPPS code being the same as those reported on the RAP. The fifth digit must be changed to a number (1-6) if the provider is aware that no non-routine supplies were used during the episode of care. In this case, the HIPPS code billed on both the RAP and the final claim was 2CHMV. However, if reporting a letter in the final position, the claim must report covered non-routine supplies. This claim does not report non-routine supplies. As such, the correct HIPPS code would be 2CHM4. Therefore, we decided that the Plan does not have to pay for the home health services provided from October 24, 2018, to December 22, 2018.