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

We decided that the Plan does not have to pay for the dental cleaning you received on December 6, 2019.
You asked the Plan to pay for the dental cleaning. You say that you assumed dental cleanings were covered. The Plan denied your request. The Plan says the service is not covered under your benefit 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. Although the Plan offers a dental benefit in excess of Medicare coverage, the provided services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning you received on December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided December 23 -December 25, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the services were provided in good faith. You say that the medical records supplied support the level of service provided.The Plan denied your request. The Plan says that an inpatient hospital stay was not medically necessary. The Plan says that the enrollee's care needs could have been provided at an alternative care level such as observation status or an acute nursing facility.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted to noncompliance with daily dose of Keppra. The enrollee had a seizure while in ambulette. The enrollee had no seizure episode while in emergency department and was treated successfully with Keppra. The enrollee remained medically stable and she was admitted to hospital for seizure 2/2 noncompliance. There was no evidence of refractory seizure or acute comorbidities such as ACS.The enrollee remained asymptomatic throughout the observation period. on December 24, 2019 the enrollee was alert and awake and was at a mental status baseline. The enrollee was neurologically intact and hemodynamically stable. The enrollee was stable hemodynamically throughout observation period. She was discharged home on December 25, 2019. The record showed that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlierED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided December 23 -December 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on September 26,
2019.
You asked the Plan to waive the copayment for the chest x-ray. You say that the wrong test was performed.
You say that you don't want to pay the copayment. 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 $15
copayment for x-rays.
You have been asked to pay a $15 copayment for the chest x-ray. The chest x-ray falls 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 chest x-ray provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on October 24, 2019.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient during these services. Medicare does not pay any provider or supplier other than the hospital for services furnished to the beneficiary while an inpatient in hospital. Payment for this service would be included in the Part A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met.Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on October 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgery provided on November 13, 2019.
You asked the Plan to waive the copayment for the Moh's surgery. You say that you had the procedure done on November 20, 2019 at the same location and was not charged a 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 $300 copayment for all other outpatient services not provided in an ambulatory surgical center. You have been asked to pay a $300 copayment for the Moh's surgery. The Moh's surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 surgery provided on November 13, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 22, 2019
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was discharged from hospice on October 17, 2019. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 17, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 22, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on December 20, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora wrist-hand orthosis (L3916) provided to the enrollee on December 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this is a worker's comp case. You say that the insurance company said they would pay all medical bills. 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 $180 copayment per date of service regardless of the number of trips. You have been asked to pay a $180 copayment for the ambulance transport. The ambulance transport falls 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 for the ambulance transport provided on November 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the office advised they accepted your plan. The Plan denied your request. The Plan says the provider is out-of-network, and no prior authorization was requested to see this provider.
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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that it was prudent for you to have another test done in Florida.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were not urgent/emergent. The Plan says these services could have waited.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 lab work provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on October 19, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests were to be provided. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.You asked the Plan to pre-approve Vyzulta. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Vyzulta is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveVyzulta.Benefits for Vyzultamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950) and two crowns (D2751).
You asked the Plan to pre-approve core buildup and two crowns. You say that you need two crowns repaired. The Plan denied your request. The Plan says these services are not covered under your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) and two crowns (D2751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an above the knee prosthesis for the enrollee.You asked the Plan to pre-approvean above the knee prosthesis. The Plan denied your request. The Plan says that necessity cannot be established with the information provided.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 an above the knee prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary inthis case. The documentation does not clearly reveal that the requested prosthesis does not exceed the patient's need or is furnished in a setting appropriate to the patient's medical needs and condition. The documentation does not reveal physician progress notes with detailed activities of this patient that support that he requires a prosthesis with microprocessor and vertical shock foot. There is no physician detailed physical examination of the patient including lower extremity range of motion. The document notes the skin has erythema but it is not clear where on the body the erythema is or that there is a detailed evaluation of the patient's residual limb in the medical progress reports. The documentation is conflicting on the patient's ambulatory level. The criteria for the requested knee prosthesis has not been supported in the submitted documentation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an above the knee prosthesis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an above the knee prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approvean above the knee prosthesis for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care and hospital discharge day management provided from November 15, 2019 to November 16, 2019.
You asked the Plan to pay for the subsequent hospital care and hospital discharge day management. You say that the enrollee was not in hospice during these dates of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 1, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care and hospital discharge day management provided from November 15, 2019 to November 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two prefabricated post and cores in addition to crowns (D2954).
You asked the Plan to pre-approve the prefabricated post and cores in addition to crowns. You say that you are on a fixed income. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two prefabricated post and cores in addition to crowns (D2954).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 24, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the validity of the order for the billed service cannot be verified.
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 G0483 is definitive drug test for 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is insufficient records to show the physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 23, 2019 to October 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that you verified that this provider was in-network. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 May 23, 2019 to October 1, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Urolift procedure.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Urolift is covered when specific criteria are met. 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 benign prostatic hyperplasia, microscopic hematuria, and erectile dysfunction. Current management with tamsulosin has been effective. Uroflowmetry indicates a peak flow rate of 16 cc/s and post-void residual of 26.9 cc. Cystoscopy indicated a three centimeter prostatic urethral length and obstructing lateral lobes. Prostate volume was not provided. The criteria for coverage are not met, as the prostate size should be less than 80 cc in size and the prostate size is not documented. The requested Urolift is therefore not reasonable or 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-approve a Urolift procedure.