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

We decided that the Plan does not have to pay for physician's services provided on December 30, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on July
16, 2019.
You asked the Plan to waive the copayment for a spinal canal injection. You say that you disagree with the
charges because you have never had to pay before. 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 $500
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $500 copayment for a spinal canal injection. A spinal canal injection falls 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. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a spinal canal injection provided
on July 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), extraction (D7210), and non-intravenous conscious sedation (D9248) provided on January 18, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray, extraction, and non-intravenous conscious sedation. You say that this appointment was an emergency. You also say that emergency dental procedures are covered. The Plan denied your request. The Plan says these services are not covered under your contract under any normal circumstances.
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 first intraoral periapical x-ray (D0220), extraction (D7210), and non-intravenous conscious sedation (D9248) provided on January 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves for the enrollee.
You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee has not tried and failed a standard pump for 4 weeks.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves for the enrollee.
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 you need therapy to get better and get back home. The Plan denied your request. The Plan says you would not be able to tolerate the amount of therapy required by inpatient rehab.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided by an OON provider on December 23, 2019.
You asked the Plan to pay for the resin-based composite. You say that it was not explained to you by the provider's office prior to the services being rendered. You also say that you are on a fixed income. The Plan denied your request. The Plan says this procedure is not a covered benefit when rendered by a dentist who does not participate in the Plan's program.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided by an OON provider on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99310) provided on December 20, 2019.
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized and 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 services at issue in this appeal. The Plan did not pre-approve the service 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 the nursing facility care (99310) provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services and the electrical stimulation services provided from December 19, 2019 to February 4, 2020.You asked the Plan to pay for the therapeutic procedure services and the electrical stimulation services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the therapeutic procedure services and the electrical stimulation services provided from December 19, 2019 to February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for endovenous ablation therapy (36475) provided on March 30, 2019.
You asked the Plan to waive the copayment for the surgery. You say that you would like reconsideration as this service was medically necessary. The Plan denied your request. The Plan says this copayment has been 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 $45 copayment for surgery services provided in a specialist's office. You have been asked to pay a $45 copayment for the surgery. This surgery falls within the surgery services provided in a specialist's office 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 endovenous ablation therapy (36475) provided on March 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), an x-ray of the temporomandibular joint (D0321), a retainer crowns (D6752) for teeth # 5 and 18, the surgical extraction (D7140), the osseous surgery (D4261), the root canal (D3330), and the prefabricated post and core in addition to a crown (D2954) provided from August 3, 2019 to November 4, 2019.
You asked the Plan to pay for the dental services. You say that you went to this new dentist because you could no longer afford the dental care that you were receiving previously. You say that the prices charged are exorbitant and you could no longer afford them. You also say that you did not know you had to formally change your assigned dentist. The Plan denied your request. The Plan says the provider in this case is not the enrollee's assigned dentist.
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 provider in this case is not your assigned dentist. Dental services must be provided by your assigned dentist in order to be covered. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), an x-ray of the temporomandibular joint (D0321), a retainer crowns (D6752) for teeth # 5 and 18, the surgical extraction (D7140), the osseous surgery (D4261), the root canal (D3330), and the prefabricated post and core in addition to a crown (D2954) provided from August 3, 2019 to November 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. The Plan denied your request. The
Plan says that you have exceeded your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of twenty-four (24) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from care in the IRF setting. The Plan denied your request. The Plan says the enrollee does not meet criteria for this 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to an acute hospital on 4/27/20 with thoracic (T12-L1) epidural abscess with spinal cord compression, Vertebral Osteomyelitis and MRSA bacteremia. He was treated with antibiotics and a wound Vac to be continued until 6/12/20. He was then transferred to an LTACH on 5/5/20. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The patient is still on IV antibiotics for the epidural abscess and has pain and muscle spasms with a wound in the back and a Vac in place. He has not yet completed the LTACH stay with treatments. He needs both care by the acute care MDs and nursing in LTACH. While the patient may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care when the patient lacks motivation and encouragement to participate even once a day.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe monitoring services rendered on November 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is not supported.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 file shows that Train of Four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan doesnot have to pay forthe monitoring services rendered on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power anterior tilt system (K0108).
You asked the Plan to pre-approve the tilt system.. You say that the requested feature is medically necessary.
The Plan denied your request. The Plan says this feature is already included in the power seating system that
was approved.
The Plan must follow Medicare rules. Medicare rules say that code K0108 may not be billed for nonstandard
dimensions of a power tilt and/or recline seating system (E1002-E1008).
We looked at the file and Medicare rules. A power seating system (E1002) was already approved. Code K0108
cannot be separately billed. Based on this information, we decided that Medicare rules for coverage of the tilt
system. have not been met. Therefore, we decided that the Plan does not have to pre-approve a power anterior
tilt system (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care services provided on October 25, 2019.
You asked the Plan to waive the copayment for the wound care services. You say that you do not feel you should be liable for this 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 $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the wound care services. The wound care services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you received wound care services at a specialist's office.
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 wound care services provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93010) provided on September 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documents received do not support CPT 93010.
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 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only". We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT 93010 is not supported by the records provided. Our physician reviewer found that the available documentation in the case file does not support "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only". The medical record does not include interpretation of an electrocardiogram. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 93010) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with accessories (E2377, E2313, E2311) for a power chair.
You asked the Plan to pre-approve the expandable controller and related items. You say that the controller is medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 expandable controller and related items. Our reviewer says that the requested controller is not medically necessary. Our physician reviewer found the record shows the enrollee has sufficient upper extremity strength to control the power chair functions using the standard controls. 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 expandable controller and related items have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with accessories (E2377, E2313, E2311) for a power chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from February 20, 2020 to March 27, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs from February 20, 2020 to March 27, 2020 for a total of 4 services. The allowed amount per each Medicare Part B drug is $70.75 and 20% of that is $14.15. The total amount you owe is: $14.15 (coinsurance) x 4 (Medicare Part B drugs) = $56.60. You have been asked to pay the total coinsurance amount of $56.60 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 from February 20, 2020 to March 27, 2020.