Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay 80% for the crown. We decided that the Plan does not have to make payment beyond 80% of the Plan allowance for the crown. You asked the Plan to make additional paymentfor the crown. You say that the Plan representative you spoke with advised that the $1,295 crown was approved, and your cost would be $697.50.The Plan says that the dental claim was processed correctly according to the Plan's benefit.We decided that the Planhas to pay 80% for the 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 looked at the file and Medicare rules. The contract says that youare responsible for a 20% coinsurance of the covered plan allowance after the $100 annual deductible is met for restorations. We find that the application of 50% coinsurance for the crown is not valid based on the contract. The contract indicates that restorative dental has 20% coinsurance and that the 50%coinsuranceis for endodontic, periodontics, and oral surgery services. A crown falls more clearly into the restorative dental benefit category, so we find that this is the correct benefit. This means you cannot be asked to pay more than 20% of the plan allowance $352.50after the $100 deductible is met.Therefore, we decided that the Plan has to pay 80%for the crown. We also decided that the Plandoes not have to make payment beyond 80% of the Plan allowance for the 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the contract clearly states that you are responsible for a 20% coinsurance of the covered plan allowance after the $100 annual deductible is met for restorations.Therefore, we decided that the Plan does not have to pay more than 80%for the crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.You asked the Plan to pre-approve the compression stockings. You say that you believed that these would be covered.The Plan denied your request. The Plan says the stockings are example of wound care items which are non-covered under surgical dressing benefit because they do not meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 21, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a follow-up visit provided on February 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a follow-up visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no proper authorization was 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 a follow-up visit provided on February 28, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 3, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a follow-up colonoscopy to have a polyp removed. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient surgeries provided in an outpatient hospital facility. The medical records show that you received a diagnostic colonoscopy on December 3, 2019. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on August 29, 2019 by an out-of-network provider. You asked the Plan to pay for the dental services. You say that you are appealing your cost-share responsibility for the services you received. 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. For code D5110, the provider billed the plan $639.00. The allowed amount for the service is $620.00, the $100.00 deductible was applied to the service, making the allowed amount $520.00, and the plan paid $260.00. You are responsible for her 50% cost share, in addition to plan's $100.00 deductible, $360.00 ($520 - $260). For code D5120, the provider billed the plan $639.00. The allowed amount for the service is $620.00, and the plan paid $310.00. You are responsible for your 50% cost share, $310.00 ($620 - $310). You are responsible for 50% of the allowed amount for each service, in addition to the $100.00 that applied to the claim, $670.00 ($1,140 - $570). The $670.00 which was assessed as your cost share is correct. Therefore, we decided that the Plan does not have to pay for complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided on August 29, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the
enrollee from April 5, 2019 to May 9, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says no skilled nursing services were received during this timeframe.
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 pay for the services. Our reviewer says that the
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there
are no identifiable skilled nursing service needs. The enrollee did not require skilled nursing or therapy services
on a daily basis. The enrollee did not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for skilled nursing facility (SNF) services provided to the enrollee from April 5, 2019 to May 9,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection 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 there is no clinical evaluation, quantification of pain relief or adequate duration of pain relief greater than six months.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of documentation of the duration and degree of effectiveness of the prior Epidural steroid injection performed in October2019. Therefore, the request is deemed not medically reasonable or 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 the injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided to the enrollee on
November 11, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
services 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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records provided do not
show that the services required the presence of an independent trained observer. 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 moderate sedation services provided to the enrollee on November 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS device rental provided on December 30, 2019.
You asked the Plan to pay for the TENS device rental. You say that you submitted the claim with the correct
modifier RR and the Plan should pay this claim. The Plan denied your request. The Plan says the provider is
allowed up to two months of rental trial period and then the TENS device will have to be purchased.
The Plan must follow Medicare rules. The rules state that providers must bill with the correct modifier.
The record shows the TENS device was rented for 2 months and must now be purchased. Specifically, NU is
the correct modifier to meet Medicare guidelines. Based on this information, we decided that Medicare rules
for coverage of services billed with an RR modifier have not been met. Therefore, we decided that the Plan
does not have to pay for the TENS device rental provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left robotic arm brace/powered upper extremity range of motion assist device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the enrollee's health problem.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro Orthosis is not the most appropriate available supply or level of service for the enrollee considering potential benefits to the patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes for hemiparesis after stroke. The MyoPro is not in widespread use based on scientific evidence for post stroke hemiplegia. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve her hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase the enrollee's participation in bimanual activities. Additional controlled studies of the MyoPro requested device for upper extremity paralysis after stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long term follow up. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a left robotic arm brace/powered upper extremity range of motion assist device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power scooter.You asked the Planto pre-approvethe scooter. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare criteria requires there be documentation that there is no sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that your mobility deficit is unable to be helped by the use of a walker or a manual wheelchair that can contain your oxygen. There is no evidence of a home evaluation indicating the requested scooter can be safely navigated in your home.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 scooter have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99406 provided on September 16, 2019.
You asked the Plan to pay for CPT code 99406. 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 99406 is Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes. We find that CPT code 99406 is not supported in the medical record. Specifically, CPT code 99406 is a time based code. In order to bill CPT code 99406, the documentation must note that greater than 3 and up to 10 minutes of smoking and tobacco use cessation counseling was provided. The progress note for September 16, 2019 does not note how much of the time spent was for smoking and tobacco use cessation counseling. As such, the provided documentation does not support the billing of CPT code 99406. Therefore, we decided that the Plan does not have to pay for CPT code 99406 provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on November 11, 2019.
You asked the Plan to pay for the wound care supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says these supplies are already included in the payment that the SNF receives for the covered stay.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. Theses supplies would have been included in the global payment submitted to the plan by the facility. Records show that the wound care supplies were used in a SNF. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided on November 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pulmonary ventilation and perfusion imaging rendered on December 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 forthe pulmonary ventilation and perfusion imaging rendered on December 16, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you have a bad right knee and do not have good balance. You stated that you have to use a walker and have come close to falling in the shower previously. You say that you really need the shower chair because of the risk involved with showering.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 81292, 81295, 81403, 81404, 81405, 81406) provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the services. You say that this is a critical component of cancer care, and is instrumental in decoding cancer to better understand the biology driving tumor growth. The Plan denied your request. The Plan says this is inappropriate billing, not supported by the documentation received and reviewed.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have recurrent endometrial cancer. Testing specifically related to endometrial cancer, the results of which would actually affect disease management, are considered to be medically necessary and reasonable. General cancer screening and wide-ranging panel testing are not medically necessary or reasonable. Such testing includes tests that are not related to a specific diagnosis and tests that are not associated with known therapies/treatments. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (CPT 81292, 81295, 81403, 81404, 81405, 81406) provided to the enrollee on June 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown provided on January 10, 2020.You asked the Plan to pay forthe crown.. You say that this service should be covered because you received a predetermination on your prior plan saying the service would be covered.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 payforthe crown provided on January 10, 2020.