Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for manual therapy provided on October 1, 2020.

You asked the Plan to pay for the manual therapy. The Plan denied your request. The Plan says there are
providers within the network that the member could have gone to for treatment.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for manual therapy provided on October 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep evaluation for the enrollee.

You asked the Plan to pre-approve the study. You say that a current titration study is medically necessary with
the current machine. The Plan denied your request. The Plan says medical necessity has not been established.

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 the study. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee feels the device is not working properly. This is best addressed first by obtaining a download
to assess usage and sleep parameters including mask leak and RDI, and by having the device assessed for
functionality by the vendor's technical staff. This has not been done. In addition, the enrollee should be
assessed with the Epworth scale for changes in daytime sleepiness. A new PAP titration study may be
necessary if the enrollee has symptoms, the device is fully functional, is being used consistently, and the RDI is
unacceptably elevated.

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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep evaluation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on January 13, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you believe these services should be covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded.
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, comprehensive oral evaluation is limited to one procedure every three years, and full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that the enrollee received a comprehensive oral evaluation on October 1, 2019, and the enrollee received a complete series of intraoral x-rays on March 27, 2019, and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on January 13, 2021.
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 26, 2020 to November 30, 2020.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 claim was billed with an inappropriate bill type. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 26, 2020 to November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
November 21, 2020, through November 27, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
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 $220
copayment per day for the first seven days and a $0 copayment per day for days 8-90, for in-network Medicare covered
inpatient hospital care.
You have been asked to pay $1,100 ($220 copayment x 5 days) for the in-network Medicare-covered inpatient
hospital care provided. 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 inpatient hospital care
provided from November 21, 2020, through November 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 18, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 25, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the office staff told you there wouldn't be a copayment because this was a follow up from a procedure. 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 $35 copayment for a specialist visit for Medicare-covered services.

You have been asked to pay a $35 copayment for the office visit. the office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure. 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 office visit provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wound therapy pump, disposable canister and wound care set provided on December 11, 2020.
You asked the Plan to waive the coinsurance for the wound therapy pump, disposable canister and wound care set. You say that the facility's wound care equipment was not working so they used your equipment. You say that you shouldn't be required to pay for wound care equipment that was only used in the skilled nursing facility. 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 durable medical equipment and related supplies. You have been asked to pay a total of $274.80 for the wound therapy pump, disposable canister and wound care set.
Service                                    Allowed Amount             Coinsurance              Member Liability
Wound Therapy Pump                   $904.54                          20%                          $180.91
Disposable Canister                       $86.50                           20%                           $17.30
Wound Care Set                           $382.95                          20%                           $76.59
TOTAL:                                                                                                               $274.80
The wound therapy pump, disposable canister and wound care set fall within the "Durable medical equipment (DME) and related 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 coinsurance for the wound therapy pump, disposable canister and wound care set provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injections (ESI).

You asked the Plan to pre-approve injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (64483) and Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484). You say that you need to have the epidural injections periodically. The Plan denied your request. The Plan says the records do not show a disc that has moved out of place, spinal canal narrowing or severe disc disease.

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 injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (64483) and Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the patient has clear indications for an ESI, there is inadequate documentation of the degree and duration of the pain relief produced by the prior
injections. Therefore, the request is deemed not medically reasonable and necessary at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (64483) and Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) (64484) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injections (ESI).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost sharing for the total knee arthroplasty (27447), laboratory services (82947 x 3), physical therapy (97161), and occupational therapy (97165) provided from December 15, 2020, through December 16, 2020.

You asked the Plan to adjust the cost sharing. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the services provided.

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 outpatient surgery. Additionally, you must pay a $12 copayment for Medicare-covered lab tests and a $40 copayment for each Medicare-covered therapy visit in an outpatient setting. 

You have been asked to pay $2,385.92. This amount includes a coinsurance for the arthroplasty surgery of $2,344.58 (Plan allowed amount of $11,722.91 x 20%). This cost additionally includes a copayment of $6.29 for laboratory services and $35.05 for therapy services, which is less than the applicable copayments for these 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 adjust the cost sharing for the total knee arthroplasty (27447), laboratory services (82947 x 3), physical therapy (97161), and occupational therapy (97165) provided from December 15, 2020, through December 16, 2020.

Your complaint about being advised by a health plan representative that the planned surgery would have a lower applicable copayment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on January 5, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you did not receive a list of in-network providers. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.

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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on January 5, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided on August 31, 2020.

You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this code is not documented.

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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on August 31, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia (Denosumab) for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this request does not meet medical necessity criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found in postmenopausal women with osteoporosis, denosumab reduces the incidence of vertebral, nonvertebral, and hip fractures. Denosumab also increases bone mass in men at high risk for fracture who are receiving androgen deprivation therapy for nonmetastatic prostate cancer, and in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer. The review has determined that the documentation supports that Prolia is medically reasonable and necessary. The documentation supports that the drug is safe and effective.

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 drug have been met. Therefore, we decided that the Plan has to pre-approve Prolia (Denosumab) for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the unna boot strapping provided on September 1, 2020, September 4, 2020 and September 8, 2020.
You asked the Plan to waive the copayment for the unna boot strapping. You say that you don't feel responsible for the out-of-pocket cost. 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 per visit for outpatient surgery or procedure. You have been asked to pay a total of $611.25 for the unna boot strapping.
Date of Service                  Service                      Allowed Amount          Standard Copayment         Member Liability
September 1, 2020    Unna Boot Strapping               $203.75                            $250                           $203.75
September 4, 2020    Unna Boot Strapping               $203.75                            $250                           $203.75
September 8, 2020    Unna Boot Strapping               $203.75                            $250                           $203.75
TOTAL:                                                                                                                                           $611.25
The unna boot strapping falls within the "Outpatient hospital services" 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 unna boot strapping provided on September 1, 2020, September 4, 2020 and September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and preventive procedure (D1999) provided on January 4, 2021.

You asked the Plan to pay for the bitewing x-rays and preventive procedure. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered by 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. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and preventive procedure (D1999) provided on January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 27, 2020 by a non-network 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 a non-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 referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided 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 laboratory services provided on May 27, 2020 by a non-network provider.