Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses coded L1851, L2397, and L0650 provided on December 9, 2019.
You asked the Plan to pay for the orthoses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 L1851, L2397, and L0650 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the member and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses coded L1851, L2397, and L0650 provided on December 9, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to approve continued skilled nursing facility (SNF) services from March 25, 2020 to March 30, 2020.You asked the Plan to approve SNF care. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before March 25, 2020. The Plan states in the file that they were unable to provide a NOMNC. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to approve continued skilled nursing facility (SNF) services from March 25, 2020 to March 30, 2020.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on September 10,
2019.
You asked the Plan to pay for the x-ray 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 separately 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, we have confirmed that code 71045
for the x-ray services has a bundled relationship with code 32557 and cannot be paid as billed. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on
September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on December 27, 2019.
You asked the Plan to pay for the dental service. You say that you just went for a general cleaning. You say that the procedure you received was part of that. You also say that you were never advised that it was a separate procedure. The Plan denied your request. The Plan says the comprehensive periodontal evaluation is not listed as a covered service.
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 comprehensive periodontal evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on December 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental consultation (D9310) treatment of root canal obstruction (D3331) endodontic therapy (D3330) and unspecified adjunctive procedure (D9999).
You asked the Plan to pay for the dental services. You say that you have provided proof that the services provided is covered. It was in your plan documents. You have followed the guidelines for having this procedure done. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
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 health plan contract specifically says that services performed by an out of network dentists is not covered. 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 dental consultation (D9310) treatment of root canal obstruction (D3331) endodontic therapy (D3330) and unspecified adjunctive procedure (D9999).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the services you received.
You asked the Plan to adjust the cost share. You say that the services were provided at an in-network facility. The Plan denied your request. The Plan says the services were received out-of-network.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $350 deductible for out-of-network services. Review of the file shows that you were provided out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $350 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the services was received. This means that you have been asked to pay the correct amount ($73.49) based on your contract with the Plan. Therefore, we decided that the Plan does not have to adjust the cost share for the services you received.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from December 3, 2019 to December 10, 2019.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 are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from December 3, 2019 to December 10, 2019.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 22, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation provided from September 11, 2019 through November 25, 2019.
You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you weren't informed of any out-of-pocket costs. 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 $20 for each visit for cardiac rehabilitation. You have been asked to pay $15.30, which is less than the standard $20 copayment for each cardiac rehabilitation visit. The total amount you owe is $413.10 ($15.30/visit x 27 visits = $413.10). Cardiac rehabilitation falls within the "Cardiac rehabilitation 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 cardiac rehabilitation provided from September 11, 2019 through November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital facility fee provided.
You asked the Plan to waive the copayment for the outpatient hospital facility fee. 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 services in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says 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 $325 copayment for each Medicare-covered non-surgical visit in an outpatient clinic. We looked at the file, the Plan's contract and Medicare rules. The file shows you received services in an outpatient hospital facility. You have been asked to pay a $325 copayment for the outpatient hospital facility fee. The outpatient hospital facility fee falls within the Outpatient hospital care 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 outpatient hospital facility fee provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.
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 procedure codes 64999 and 31299 are 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 64999 is unlisted procedure, nervous system. The definition of code 31299 is unlisted procedure, accessory sinuses. We find that CPT codes 64999 and 31299 are not supported in the medical record. Specifically, the operative report does not contain documentation of an unlisted procedure of the nervous system to support code 64999 or an unlisted procedure of the accessory sinuses to support code 31299. 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 pay for the surgical services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on December 13, 2019.
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 enrollee was on hospice.
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 testing services rendered on December 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for a duplex scan and a specialist office visit provided on December 3, 2019 and December 5, 2019.
You asked the Plan to waive the copayments for the duplex scan and the specialist office visit. You say that you cannot afford the copayments. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan applied copayments from different counties. Since the Plan did not confirm which plan the member is enrolled in, we cannot determine if the copayments that were applied are correct. Therefore, we decided that the Plan has to waive the copayments for a duplex scan and a specialist office visit provided on December 3, 2019 and December 5, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on December 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says this provider is not in-network and there is no authorization on file. The Plan says that these services were not plan directed. The Plan says no approved nursing facility claim was received.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 forskilled nursing services provided on December 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for zinc air battery for use with cochlear implant device (L8621) purchased November 5, 2019.
You asked the Plan to pay for Zinc air battery. You say that the original supplier quit supplying the disposable batteries and recommended another outlet. Since going to them you have not been able to get reimbursed. The Plan denied your request. The Plan says the plan cannot pay a provider who is not eligible to participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zinc air battery have not been met. Therefore, we decided that the Plan does not have to pay for zinc air battery for use with cochlear implant device (L8621) purchased November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says the use of this drug requires migraines for greater than or equal to 15 days each month, each lasting more than four hours a day or longer.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 injection. Our reviewer says that the requested Botox is not medically reasonable or necessary. Our physician reviewer found in this case Botox has been prescribed for the prophylaxis of migraine headaches. The office visit note provided for review largely focused on the enrollee's ophthalmological condition(s). There was very limited information about the headaches. The enrollee was noted to have mild headaches daily which lasted at least 3 hours. She was said to have taken to piramate in the past. However, the records did not indicate that the enrollee has at least 8 headache days per month that meet criteria for migraine without aura or respond to migraine-specific treatment. Nor can it be determined from the note provided that the enrollee's migraines have (caused) significant disability due to the headaches, and have been refractory to standard and usual conventional therapy. In as much the requirements of the LCD for coverage have not been met in this case. In as much the requirements for Botox as outlined in the LCD have not been 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 the injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Botox for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the face masks (E1399).
You asked the Plan to pre-approve the face masks. You say that you are not able to go into grocery stores or gas stations due to not having a mask and you're denied access to facilities. The Plan denied your request. The Plan says this is considered a convenience item and is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the face masks (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillary partial denture with a flexible base provided on January 13, 2020.You asked the Plan to pay forthe maxillary partial denture. You say that the metal material used for the dental bridge gives you an allergy, which does not allow you to use it.The Plan denied your request. The Plan says maxillary partial denture with flexible base 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 maxillary partial denture with flexible base is not among those covered under this benefit. This plan only covers removable partial dentures with an acrylic or metal base.Therefore, we decided that the Plan does not have to pay forthe maxillary partial denture with a flexible base provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need this because of your urinary incontinence. The Plan denied your request. The Plan says that Medicare does not cover incontinence supplies.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were not informed you would be responsible for ambulance fees. The Plan denied your request. The Plan says that the cost share was 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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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.