Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve abdominal panniculectomy.
You asked the Plan to pre-approve abdominal panniculectomy. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that only services that are reasonable and necessary for
the diagnosis or treatment of illness or injury are coverable.
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 abdominal panniculectomy. Our
reviewer says that the documentation supports that the requested services are medically reasonable and
necessary. Our physician reviewer found you had weight loss, which has resulted in having loose skin which
hangs below your abdomen. The documentation supports clear evidence of functional impairment (chronic
rashes) associated with overlapping soft tissue of the lower abdomen. This has failed conservative management
with typical dermatologic management (Nystatin). Since you have a functional deficit directly related to the
excess soft tissue of the abdomen that has failed reasonable conservative management and would likely
improve with surgical correction, abdominal panniculectomy satisfies Medicare medically necessary criteria.
Therefore, you meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of abdominal panniculectomy have been met. Therefore, we decided that the Plan
has to pre-approve abdominal panniculectomy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental x-rays you received on July 27, 2020.You asked the Plan to pay forthe x-rays. The Plandenied your request. The Plan says this is only covered once per year.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the x-rays when the services are medically necessaryand reasonable. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are subject to a benefit limitation. The Plan covers dental x-rays one per year. The records show that you were provided covered dental x-rays on January 23,2020. The requested x-rays exceed the benefit limit.Therefore, we decided that the Plan does not have to pay forthe dental x-rays you received on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora walker purchased by the enrollee on June 29, 2020.You asked the Plan to pay fora walker ordered by the enrollee. You say that this walker was medically necessary for the enrollee.The Plan denied your request. The Plan says claims cannot be paid by Medicare to this provider.The Plan must follow Medicare rules. Medicare allows Plans to require prior authorization. Medicare requires enrollee's wo use Medicare eligible providers. Durable medical equipment purchased privately through agents or by private purchase are not eligible for coverage by your Medicare governed health plan. The enrollee did not have prior authorization for this purchase. The Plan contract rules were not followed when this equipment was purchases. Therefore, we decided that the Plan does not have to pay fora walker purchased by the enrollee on June 29, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300,
E2311, E2377, E2313) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the expandable harness (E2313), the (E2311) electronic connection, and the (E2377)
expandable controller are not medically necessary. The documentation does not reveal that the patient needs an
expandable controller to operate other types of proportional input devices (e.g., mini-proportional or compact
joysticks, touchpads, chin control, head control, etc.), non-proportional input devices (e.g., sip and puff, head
array, etc.), or to operate 3 or more powered seating actuators through the drive control. The documentation
does not reveal the patient needs the expandable controller to operate a separate display (i.e., for alternate
control devices),other electronic devices (e.g., control of an augmentative speech device or computer through
the chair's drive control), or for an attendant control. The patient has function in the upper limbs (i.e.
independent in self feeding and dressing) to control any power options through their individual switches.
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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional power wheelchair accessories (E2300, E2311, E2377, E2313) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for outpatient surgery provided.

You asked the Plan to waive the co payment for outpatient surgery. You say that you previously had the same procedure with only a $10 co payment.The Plan denied your request. The Plan says the co payment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 co payment for in-network outpatient surgery at an outpatient hospital facility. 

You have been asked to pay $50 c opayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including 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 co payment for outpatient surgery provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgery provided on June 4, 2020.You asked the Plan to waive the copayment forthe outpatient surgery. You say that this should be paid in full by Medicare.The Plan denied your request. The Plan says that the claim 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 $450 copayment for outpatient surgery provided in an Outpatient hospital. You have been asked to pay a $450 copayment for the outpatient surgery. The outpatient surgery falls within the outpatient surgery provided in an Outpatient hospital 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 forthe outpatientsurgery provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic services provided to the enrollee
on May 28, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network chiropractic services.
Medicare allows Plans to require prior authorization. The Plan contract states that out of network care requires
prior authorization. The enrollee did not have prior authorization as was required by the Plan contract.
Therefore, we decided that the Plan does not have to pay for out of network chiropractic services provided to
the enrollee on May 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF care provided from August 1, 2020, to August 20, 2020.You asked the Plan to waive the copayment forthe SNF care. You say that you feel that you should not be billed for the last day.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 21 days, resulting in a total copayment amount of $178.You have been asked to pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for the SNF care. The SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. This meansthat 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 SNF care provided from August 1, 2020, to August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forEuflexxainjections (J7323) provided from July 29, 2020, to August 12, 2020.You asked the Plan to waive the coinsurance forEuflexxa injections. You say that you were not charged for these injections in the past.The Plan denied your request. The Plan says these services 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for Euflexxa injections, which 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 forEuflexxa injections (J7323) provided from July 29, 2020, to August 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not
payable.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ambulance services provided on May 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic test provided on July 7, 2020.
You asked the Plan to waive the copayment for the diagnostic test. 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 a diagnostic test in your primary care physician's office 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 $10 copayment for diagnostic procedures and tests provided in a primary care physician's office. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic test provided to you in your primary care physician's office on July 7, 2020. You have been asked to pay a $10 copayment for the diagnostic test. The diagnostic test falls 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 diagnostic test provided on July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator (C1767, C1820).
You asked the Plan to pre-approve a neurostimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved when a procedure for insertion has not been requested.
The Plan follows Medicare rules. Medicare rules say sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention with the limitations listed 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 a neurostimulator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the indications for sacral neuromodulation are overactive bladder and non-obstructive urinary retention. The medical records do not support that these indications are present. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator (C1767, C1820).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided on July 1, 2020.You asked the Plan to waive the copayment forthe ambulance 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 ambulance 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 $380 copayment for Ambulance services.We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance services on July 1, 2020. You have been asked to pay a $380 copayment for the ambulance services. The ambulance services fall within the Ambulance 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 forthe ambulance services provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental extractions you received on June 2, 2020.You asked the Plan topay forthe extractions. The Plan denied your request. The Plan says only two extractions are covered per year.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 services are subject to a benefit limitation. The Plan covers two dental extractions per calendar year. The records show that the Plan has paid for two extractions. The additional extractions exceed the benefit limit and are not covered.Therefore, we decided that the Plan does not have to pay forthe dental extractions you received on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services with CPT code S9328 provided from May 12, 2020 to July 22, 2020.You asked the Plan to pay forCPT code S9328. 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 providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Based on this information, we decided that Medicare rules for coverage of CPT code S9328 have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services with CPT code S9328 provided from May 12, 2020 to July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory test with CPT code 87631 provided on June 26, 2020.You asked the Plan to pay forCPT code 87631. 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 providers must report services correctly.We looked at the file and Medicare rules. CPT code 87631 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. Based on this information, we decided that Medicare rules for coverage of CPT code 87631 have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory test with CPT code 87631 provided on June 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator.You asked the Plan to pre-approvea home ventilator. You say that the requested home ventilator is medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for a home ventilator.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.We asked our physician reviewer to carefully review the case file and apply the relevant Medicarerules to determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) requiring supplemental oxygen, but there is no documentation of CO2 retention with an arterial blood gas.  Therefore, criteria for nocturnal respiratory support such as BiPAP are not met.  A home ventilator is not medically necessary because of this, and because Medicare does not cover a home ventilator when used as BiPAP. Coverage criteria for a home ventilator are not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe filling (D2392) and the extraction (D7210) provided on July9, 2020.You asked the Plan to pay forthe dental services. You say that you were not aware that the dentist was out of network. You also say that you were scheduled to see a provider that was in network and ended up seeing this one.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered.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, dental services that you receive out of networkare not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe filling (D2392) and the extraction (D7210) provided on July 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 73060) provided.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is only allowed once per date of service.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied

.In this case, the MUE for CPT code 73060 is 2. On the date of service in question, 3 units of this code were billed, exceeding the MUE. 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 73060) provided.