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

We decided that the Plan does not have to pay for a motorized power vehicle (E1399) and a standing frame/table system (E0638) provided on October 3, 2019 by an out of network (OON) Durable medical equipment (DME) provider.You asked the Plan to pay for a motorized power vehicle and a standing frame/table system. You say that you have 2 broken vertebra, 2 knee replacements and a torn rotator cuff. You are not able to move more than 75 feet without resting and requests reconsideration of the denied claim.The Plan denied your request. The Plan says suppliers must get prior authorization before the enrollee's is able to get some durable medical equipment and the equipment must be obtained through participating plan suppliers.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 fora motorized power vehicle (E1399) and a standing frame/table system (E0638) provided on October 3, 2019 by an out of network (OON) Durable medical equipment (DME) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on October 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 forthe laboratory services provided on October 9, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper denture (D5110).You asked the Plan to pre-approve the dental service. You say that had you been aware that dentures were not covered you would not have had the dental provider pull all of your remaining teeth on the top. You need dentures but you cannot afford it.The Plan denied your request. The Plan says this service is not a covered under benefits 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 complete upper denture (D5110)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on August 30, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid. The Plan denied your request. The Plan says an inpatient setting was not appropriate.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. The enrollee presented to the Emergency Department on August 30, 2019 with a few days of chest pain with associated shortness of breath. On evaluation her vital signs were stable and the evaluation revealed atrial fibrillation. Cardiac biomarkers were normal. She was evaluated by Cardiology. She was admitted to telemetry and treated with Metoprolol for rate control. An echocardiogram was performed. Her condition stabilized and she wanted follow-up with her previous cardiologist. She was medically stable for discharge the following day.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on August 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the knee (73564) provided December 13, 2019 by provider.You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 an $80 copayment for radiology services. You have been asked to pay an $80 copayment for the x-ray. The x-ray falls within the radiology 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 an x-ray of the knee (73564) provided December 13, 2019 by provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on October 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that the member is in an assisted living facility; therefore, the doctor is not responsible to get authorization. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that no prior authorization was obtained.Medicare rules say that plans can require enrolleesto 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 isnot 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 forthese items/services.Therefore, we decided that the Plan does not have to pay forskilled nursing services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan.You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the requested MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI scan. Our reviewer says that the documentation does not support that the requested MRI scan is medically reasonable or necessary. Our physician reviewer found the enrollee is undergoingan evaluation for short-term memory loss. There is no clinical rationale for the requested MRI of the brain. There is no documentation indicating the requesting provider completed a trial of therapies for depression diagnosis/screen or other serum screens for altered mental status or short term memory loss, IQ guidelines not met. MRI screening for brain atrophy, a normal part of aging, is not medically necessary as there is no treatment beyond a normal and routine risk factor. Therefore, the enrollee does not meet criteria forthe 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 an MRI scan have not been met.Therefore, we decided that the Plan does not have to pre-approvean MRI scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical spine fusion for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is needed to properly address the enrollee's complaints and improve his quality of life. The Plan denied your request. The Plan says the requested procedure may be considered medically necessary and covered when there is documentation of physical and neurological abnormalities noted on physical exam that are suggestive of nerve root or spinal cord compression at the affected level.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the cervical spinal surgery is not medically needed. The EMG does not show cervical nerve root findings consistent with exam and imaging. Criteria for surgery is 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical spine fusion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevator for a wheelchair. You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 a power seat elevator for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy of a molar tooth provided on
September 12, 2019.
You asked the Plan to pay for the endodontic therapy. You say that you were not told until January 2020 that
your claim had not been approved. You also say that this was emergency dental work because the infection
passed to your palate, which was treated with antibiotics. The Plan denied your request. The Plan says this
service is 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, endodontic therapy is not covered in
molar teeth. Therefore, we decided that the Plan does not have to pay for the endodontic therapy of a molar
tooth provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical performance testing provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physical performance 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.
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 physical performance testing provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services (CPT 88342 and CPT 88305) provided to you on February 5, 2019.
You asked the Plan to pay for the services. You say that you had an appointment on February 5, 2019 with the gastroenterologist and he performed an exam, and sent the specimen to the facility. The Plan denied your request. The Plan says that there is an invalid/missing place of service.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. You were referred for the services by the physician. The physician is a contract provider for this plan for Broward County. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services (CPT 88342 and CPT 88305) provided to you on February 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76881) provided on July 29, 2019. You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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. In this case, the CPT Code Manual definition of code 76881 is ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation . We asked our coder 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 ultrasound. Our reviewer says that CPT code 76881 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include image documentation to validate that an Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation was performed on the Right side or an Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation was performed on the Left side, therefore these services cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76881) provided on July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism of the seat lift chair purchased on September 16, 2019. You asked the Plan to reimburse you for the seat lift mechanism of the seat lift chair. You say that your doctor prescribed the seat lift chair. The Plan denied your request. The Plan says the provider must be eligible to participate in Medicare. The plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism of the seat lift chair purchased on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by an out of network (OON) provider. You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network. The Plan says the services were deemed to be medically necessary; however, there was no medical reason established to warrant an out-of-network referral for the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 August 6, 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 laboratory services provided on November 1, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 laboratory services provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on January 16, 2020.You asked the Plan to pay for the dental service. You say that every year at open enrollment, you are advised that if you are satisfied with your coverage and payment from the previous year, you do not have to do anything further. You say that you were not informed of any changes to the dental coverage for 2020. You also say that you did not receive an Annual Notice of Changes for 2020.The Plan denied your request. The Plan says crowns are not 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, crowns are not among those covered under this benefit. The record shows that the Annual Notice of Coverage was sent out on September 16, 2019 and was also available online starting October 1, 2019.Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) provided on January 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe annual wellness visit provided on April 23, 2019.You asked the Plan to waive the coinsurance forthe annual wellness visit. You say that there is no fee for a wellness visit. You say that the cost shouldn't be your responsibility.The Plan denied your request. The Plan says the coinsurance 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 40% coinsurance for the out-of-network annual wellness visit.You have been asked to pay $54.79, which is 40% of the allowed amount for the annual wellness visit. The allowed amount is $136.98 (40% x $136.98 = $54.79). The annual wellness visit falls within the "Annual Wellness Visit" benefit category. The records show that the provider is out-of-network. This means that you have been asked to pay the correct amount based on your contract with thePlan. 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 forthe annual wellness visit provided on April 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis (D1110) provided on November 26, 2019.You asked the Plan to pay for the dental services. You say that you were told that you were told that you can get 2 cleanings every year so you do not understand why the claim is being denied for benefit exhausted.The Plan denied your request. The Plan says this request exceeds the maximum allowable benefit limit.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 has an annual maximum of $1000. Once the annual maximum is exhausted, they you are responsible for payment of all charges.  The records show that this benefit was applied to previous dates of services.Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on November 26, 2019.