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

We decided that the Plan does not have to pay for the office visit provided on August 19, 2019 by the out of network provider.You asked the Plan to pay for the physician service. You say that based on the portal, an authorization was not needed for the enrollee.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the service. The Plan also says the services were not urgent or emergent.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 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 office visit provided on August 19, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on August 19, 2019.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says nonemergent,
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 ophthalmological services provided on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99292 provided on June 14, 2019.
You asked the Plan to pay for CPT code 99292. 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. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99292 is Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT code 99292 is not supported in the medical record. Specifically, CPT code 99292 is a time based code. In order to bill CPT code 99292, the documentation must note that an additional thirty minutes was spent providing critical care services to the enrollee on June 14, 2019 in addition to the first 30-74 minutes of critical care services. As such, the provided documentation does not support the billing of CPT code 99292 for June 14, 2019. Based on this information, we decided that Medicare rules for coverage of CPT code 99292 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99292 provided on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for the physician services provided on July 30, 2019 and August 20, 2019.
You asked the Plan to waive the deductible and coinsurance for the physician services. You say that you were told the provider was in-network. 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. Your contract with the Plan says that there is a $490 combined deductible that applies towards out-of-network physician services and 50% of the cost for each specialist visit for Medicare-covered benefits. The physician services you asked the Plan to waive the deductible and coinsurance for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $490 combined deductible that applies towards out-of-network physician services and 50% of the cost for each specialist visit for Medicare-covered benefits. The record shows the provider is out-of-network. See chart below.
Date of Service
Service
Allowed Amount
Deductible/Coinsurance
Member Liability
July 30, 2019
Specialist office visit
$118.99
$490.00
$118.99
July 30, 2019
Lesion destruction
$146.44
$490.00
$146.44
July 30, 2019
Destroy 2-14 lesions
$38.09
$490.00
$38.09
July 30, 2019
Destruction, laser
$36.40
$490.00
$36.40
July 30, 2019
Biopsy of skin
$54.72
$490.00
$54.72
Total for July 30, 2019
$394.64 - applied to deductible
August 20, 2019
Wound Repair
$341.30
$490.00
$95.36
($490 - $394.64). This is where you met the deductible amount.
$245.94
($341.30 - $95.36)
50%
$122.97
August 20, 2019
Excision
$94.30
50%
$47.15
Total
(July 30, 2019 and August 20, 2019)
$660.12
This cost sharing is a contractual obligation that had not been met at the time the physician services were received on July 30, 2019 to August 20, 2019. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for the physician services provided on July 30, 2019 and August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 9, 2019 by the out of
network provider.
You asked the Plan to pay for an office visit. You say that you were unaware that prior authorization was
required. The Plan denied your request. The Plan says 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 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 9, 2019 by the
out of network provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the replacement crown for tooth #2. We decided that the Plan does not have to pre-approve replacement crowns for teeth #12 and #14.
You asked the Plan to pre-approve the replacement crown for tooth #2. You say that you have sensitivity in your teeth and the dentist wants to replace the bad crowns. The Plan says that the documentation provided does not demonstrate the need for replacement of the existing crowns.
We decided that the Plan has to pre-approve the replacement crown for tooth #2.
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 replacement of crowns when the services are medically necessary and reasonable. 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 crown for tooth #2. Our reviewer says that this enrollee partially meets the criteria. Our physician reviewer found the radiographs reveal recurrent caries at the crown margin of tooth #2. At this time a replacement crown on tooth #2 is reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage for a replacement crown on tooth # have been met. Therefore, we decided that the Plan has to pre-approve the replacement crown for tooth #2.
We also decided that the Plan does not have to pre-approve replacement crowns for teeth #12 and #14.
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 replacement of crowns when the services are medically necessary and reasonable 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 replacement crowns for teeth #12 and #14. Our reviewer says that this enrollee partially meets the criteria. Our physician reviewer found a review of the open margins of teeth #12 and 14 were indicated on the buccal surfaces, but are not visible on radiographs. Unless additional information is submitted verifying recurrent caries on teeth #'s 12 and 14 that cannot be treated by restorations, the criteria for replacement crowns 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 for the replacement of crowns for teeth #12 and #14 have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement crowns for teeth #12 and #14.
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 services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, medical necessity for IRF care has not been established. Therefore, coverage criteria has not been met.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear you would be able to fully benefit and/or participate in an IRF 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance service (A0429) and ground mileage (A0425) provided on July 24, 2019.You asked the Plan to pay for the ambulance services. You say that you are requesting reconsideration and reprocess the claim.The Plan denied your request. The Plan says the information does not support the medical necessity for ambulance transport.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the documentation did not support that the ambulance transport was medically reasonable and necessary. Our physician reviewer found the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. Vital signs were stable and required no ongoing monitoring. There was no need for 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 the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay for emergency ambulance service (A0429) and ground mileage (A0425) provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.You asked the Plan to pre-approve a CardioMEMS device. 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 a CardioMEMS device. Our reviewer says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this circumstance, therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered experimental or investigational.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 CardioMEMS device have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve replacement of metal crown tooth 18 (D2792) to be provided. You asked the Plan to pre-approve the crown. You say that please reconsider the request for the crown.The Plan denied your request. The Plan says that the documentation provided does not demonstrate the need for replacement of the existing crown.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 crown when the services are medically necessary and reasonable.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 crown. Our reviewer says that this enrollee does meet the criteria. Our physician reviewer found the crown presently in place was placed prior to 1997 according to the record and has lost the porcelain covering leaving the metal coping. A coping does not provide adequate occlusal contact nor proper contact points with the adjacent teeth The criteria for a replacement crown are met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met.Therefore, we decided that the Plan has to pre-approve replacement of metal crown tooth 18 (D2792).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 for bitewings - four radiographic images (CPT Code D0274) provided by an out-of-network provider, on August 1, 2019.
You asked the Plan to pay for the dental services. You say that you state you did not receive any x-rays on this date of service. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Review of the file show that you received bitewings - four radiographic images (CPT Code D0274) provided by an out-of-network provider on August 1, 2019. Therefore, you are asked to pay 50% coinsurance for out-of-network dental x-rays. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (CPT Code D0274) provided by an out-of-network provider, on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Allopurinol 100MG tablet for the enrollee.
You asked the Plan to pre-approve Allopurinol. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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-approve Allopurinol 100MG tablet.
Benefits for Allopurinol 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain or ceramic pontic, endodontic therapy, first
15 minutes of deep sedation or general anesthesia, and each subsequent 15 minute increment of deep sedation
or general anesthesia.
You asked the Plan to pre-approve the pontic, endodontic therapy, and deep sedation or general anesthesia
services. You say that you need teeth and do not understand why the Plan would deny these services. The Plan
denied your request. The Plan says these services are not covered under your benefit package.
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 a
porcelain or ceramic pontic, endodontic therapy, first 15 minutes of deep sedation or general anesthesia, and
each subsequent 15 minute increment of deep sedation or general anesthesia.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for initial hospital care (CPT Code 99223) provided to the enrollee on March 4, 2019.
You asked the Plan to pay for the services. You say that the facility is responsible for obtaining authorization. The Plan denied your request. The Plan says that non-contracted providers must obtain authorization before services are rendered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. This service was provided in the context of an emergency hospital admission, authorization would never be required for the physician consultation provided during the admission. Therefore, we decided that the Plan has to pay for initial hospital care (CPT Code 99223) provided to the enrollee on March 4, 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on April 9, 2019.You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on April 9, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the copayments for chemotherapy services provided from April 16, 2019 to August 9, 2019.
You asked the Plan to waive the copayments for chemotherapy services. You say that you should not owe a
copayment. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $0 copayment for Medicare Part B prescription drugs.
This includes drugs that usually are not self-administered by the patient and are injected or infused while you
are getting physician services.
The Plan says you must pay a $10 copayment for chemotherapy services. Based on the Plan contract, however,
you cannot be asked to pay more than a $0 copayment for chemotherapy services. Therefore, we decided that
the Plan has to waive the copayments for chemotherapy services provided from April 16, 2019 to August 9, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a water circulating cold pad.You asked the Plan to pre-approve a water circulating cold pad (E0218). You say that you need a water circulating coldpad to decrease the swelling after surgery.The Plan denied your request. The Plan says a water circulating cold pad is not covered by Medicare or the Plan.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 a water circulating cold pad.