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

We decided that the Plan has to pay for the panoramic x-ray provided on December 23, 2019.
You asked the Plan to pay for the panoramic x-ray. You say that you signed to have your x-rays from another dental provider emailed to this treating provider. You also say that this treating dentist needed a more complete view. The Plan denied your request. The Plan says that this service exceeds the frequency limitation in the benefit plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. We looked at your contract with the Plan. The record shows that you received a complete series of intraoral x-rays on November 14, 2019. The contract states that complete series of intraoral x-rays are limited to one procedure every three years. The contract does not clearly state that either a complete series of intraoral x-rays or a panoramic film is covered once every three years. You reasonably believed that you were able to have one of each of these x-rays covered every three years. This means that the Plan did not follow Medicare rules for disclosure of the dental benefits. Therefore, we decided that the Plan has to pay for the panoramic x-ray provided on December 23, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe collagenase injection provided on December 3, 2019.You asked the Plan to waive the coinsurance forthe collagenase injection. You say that you don't understand the cost of the bill. You say that you were informed the cost would be $40.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B.You have been asked to pay $1,620, which is 20% of the allowed amount for the collagenase injection. The allowed amount is $8,100 (20% x $8,100 = $1,620). The collagenase injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe collagenase injection provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 8, 2019 through November 12, 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. 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 shows that you were admitted on November 8, 2019 and discharged on November 12, 2019. You were asked to pay a $200 copayment per day from November 8, 2019 through November 11, 2019, days 1-4 of your inpatient hospital care. You were discharged on November 12, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $200 copayment per day required for days 1-7. 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 from November 8, 2019 through November 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted case management provided on October 9, 2019 by the provider.
You asked the Plan to pay for targeted case management. You say that the services were necessary and should be covered. 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 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 pay for targeted case management. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, documentation does not show if this enrollee is currently taking any medication, is in therapy or the reason for the requested services. This enrollee does not require targeted case management services for the treatment of mental disorder not otherwise specified as it is not considered medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of targeted case management have not been met. Therefore, we decided that the Plan does not have to pay for targeted case management provided on October 9, 2019 by the provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genomic sequence analysis panel provided to the enrollee
on March 27, 2019.
You asked the Plan to pay for the services provided. You say that the testing is necessary for the diagnosis,
monitoring, and medical management of the enrollee. The Plan denied your request. The Plan says the service
is not covered.
The Plan must follow Medicare rules. Medicare rules say that , the information submitted by the supplier or
provider must corroborate the documentation in the beneficiary's medical documentation.
We find that CPT code 81450 is not supported in the medical record. Specifically, there were insufficient
records provided to show the results of this testing would be used to determine a specific diagnosis or
determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Based
on this information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for the genomic sequence analysis panel provided to
the enrollee on March 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on December 2, 2019.
You asked the Plan to pay for incontinence supplies. You say that the enrollee is eligible for these 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 pay for incontinence supplies provided on
December 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.
You asked the Plan to pre-approve the PET scan services. You say that the records provided support the need
for the requested PET scan. The Plan denied your request. The Plan says there was not enough medical
evidence in the documentation provided to support the medical necessity criteria.
The Plan must follow Medicare rules. Medicare rules say that PET 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 was correct in denying the request to pre-approve the PET scan services. Our reviewer
says that the requested PET scan is not medically necessary. Our physician reviewer found the enrollee has a
medical history that includes renal cell carcinoma diagnosed in 2003. The enrollee had a partial left
nephrectomy; follow-up imaging in the provided records shows no evidence of cancer recurrence. On March
12, 2020 there is a medical note indicating a complaint of a right shin leg lump. The medical records do not
show that there is a covered indication for a PET scan 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 PET scan services have not been met. Therefore, we decided that the Plan
does not have to pre-approve positron emission tomography (PET) scan services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora laparoscopy (49656) provided on November 15, 2019. You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration as this service was billed correctly and should be payable to the assistant surgeon.The Plan denied your request. The Plan says the covered services for this provider is reimbursed indirectly, when in facilities, through the payment methodology for the facilities.The Plan must follow Medicare rules. Medicare rules say that no provideror supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Specifically, the record indicates that this provider is a Registered Nurse. Per Medicare, Registered Nurses are not eligible to enroll in Medicare.Therefore, we decided that the Plan does not have to pay for a laparoscopy (49656) provided on November 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on November 8, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you already met the MOOP amount for the year and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay MOOP amount for 2019 is $4,500. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on November 8, 2019. The record shows that you had only paid $3,164.25 toward the $4,500 MOOP amount. Therefore, you are responsible to pay $1,105.75, which is less than the 20% coinsurance amount. You have been asked to pay $1,105.75 for Medicare Part B drugs. Medicare Part B drugs 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 Medicare Part B drugs provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on December 17, 2019 and x-ray on December 31, 2019.
You asked the Plan to waive the copayment for the CT scan and x-ray. You say that you were informed all tests would be covered. You say that the billing should be corrected. The Plan denied your request. The Plan says the copayments 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 $250 copayment for advanced imaging services at an in-network outpatient hospital and a $95 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a total of $301.91 for the CT scan and x-ray.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
December 17, 2019
CT Scan
$206.91
$250
$206.91
December 31, 2019
X-Ray
$206.91
$95
$95
TOTAL:
$301.91
The CT scan and x-ray 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 copayment for the CT scan provided on December 17, 2019 and x-ray on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift recliner purchased on November 6,
2019.
You asked the Plan to reimburse you for the seat lift mechanism of the seat lift recliner. You say that you
should get some sort of reimbursement. The Plan denied your request. The Plan says seat lift recliners are
considered a convenience item and not eligible for reimbursement.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met. Medicare does not pay for the upholstered portion of a seat lift chair.
We looked at the file and Medicare rules. There are no medical records to support medical necessity. Also, the
chair was purchased from an out-of-network provider without authorization. Based on this information, we
decided that Medicare rules for coverage of the seat lift mechanism of the seat lift recliner have not been met.
Therefore, we decided that the Plan does not have to reimburse you for the seat lift recliner purchased on
November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forimmunizations provided on December 30, 2019.You asked the Plan to pay forpreventative immunizations under Medicare Part B. You say that this bill should be covered by the Plan.The Plan denied your request. The Plan says coverage for the immunizations provided should be submitted to Medicare Part D.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative immunizations under Medicare Part B. The Plan follows the same rules. The records donot show that you have been injured or directly exposed to any illness related to preventative immunizations under Medicare Part B.Therefore, we decided that the Plan does not have to pay forimmunizations provided on December 30, 2019.Benefits for preventative immunizations under Medicare Part Bmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a fecal occult test on December 22, 2019.
You asked the Plan to pay for fecal occult test. You say that you only had 1 test but had to do it for 2 days. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 2 separate fecal occult blood tests were done so this test is not covered.
The Plan must follow Medicare rules. Medicare rules say that a fecal occult blood test is only covered once per year. We looked at the file and Medicare rules. A separate fecal occult blood test was provided less than 1 year prior to this test, therefore this test exceeds the benefit limitation according to Medicare rules and the Plan contract. Therefore, we decided that the Plan does not have to pay for a fecal occult test on December 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 18, 2019 to November 24, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was billed with an invalid type of bill for a non-participating home health provider.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include a valid type of bill code for home health services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 18, 2019 to November 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on November 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services provided are not a covered benefit.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 rest home visit provided on November 30, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 is currently undergoing treatment at an acute care hospital for a pneumothorax in the setting of COPD and lung metastasis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesix home health occupational therapy (OT) visits.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. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify theneed for home health care services.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 enrollee has unspecified dementia without behavioral disturbance. The OT home health evaluation on February 27, 2020 showed he is functioning at his prior level of function for dressing, toileting, and showering. His upper extremity range of motion is full. He has no recent falls. The records show that the enrollee does not require home health OT to improve his function or to establish/perform a maintenance program to maintain his current level of function or prevent deterioration. The six continued visits are not medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvesix home health occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 to November 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider 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 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 medical services provided on October 10, 2019 to November 21, 2019 by an out of network (OON) provider.