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

We decided that the Plan does not have to pay for outpatient hospital services.

You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says non-emergent, 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 outpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910).

You asked the Plan to pay for the dental services. You say that you did not know services was not covered. You went in for a routine cleaning and was not advised that you were getting a deep cleaning. The Plan denied your request. The Plan says this service is not covered under the plan 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. The health plan contract says that periodontal maintenance (D4910) is not covered and the enrollee is responsible for the additional charge.

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 periodontal maintenance (D4910).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that you were charged for a covered procedure. The Plan denied your request. The Plan says you were charged this copayment 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 $150 copayment for Outpatient Diagnostic Tests.

You have been asked to pay $150 copayment for the CT scan. The CT scan falls within the Outpatient Diagnostic Tests Diagnostic Radiology 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 CT scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Gel-one injection (J7326).

You asked the Plan to waive the coinsurance for the Gel-one injection. You say that you were charged less for a previous injection. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy drugs and all other drugs covered under Medicare Part B.

You have been asked to pay a total of $234.60 ($1,173 x 20% coinsurance = $234.60) for the Gel-one injection. This injection falls within the Medicare Part B prescription drugs 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 coinsurance for the Gel-one injection (J7326).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical history warrants admission to an LTACH, as this level of care is necessary for the enrollee to recover. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee is not medically stable to transfer to another level of care and needs to stay in the hospital until he is better.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0675) and segmental gradient pressure pneumatic appliance, half leg (E0673x2).

You asked the Plan to pay for intermittent limb compression device and appliance. You say that this was deemed necessary by your surgeon, for that you appreciate the caution made on your behalf. The Plan denied your request. The Plan says pneumatic compression devices coded as E0675 is used only for peripheral artery disease and is not covered. This DME is not allowed when performed at this place of service.

The Plan follows Medicare rules. The rules state that a pneumatic compressions devices coded as E0675 to treat peripheral artery disease is not eligible for reimbursement and is not medically necessary. Review of the claims show that the DME service E0673 was billed with the place of service 24 for an ambulatory surgical center. The DME must be for use in the patient's residence other than a healthcare institution and payment cannot be made for equipment for use in an institution. You can find this information in the Medicare Claims Processing Manual Chapter 20, section 10.1 and 10.2.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0675) and segmental gradient pressure pneumatic appliance, half leg (E0673x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection.

You asked the Plan to waive the coinsurance for the Part B injection. You say that you met your deductible and should not have a cost share. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each in-network and out-of-network Medicare-covered Part B drug obtained in a provider's office or outpatient setting.

You have been asked to pay $123.53 which is 20% of the allowed amount for the Part B injection. The allowed amount is $617.67. ($617.67 x 20% = $123.53). The Part B injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the Part B injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI of the brain (70551).

You asked the Plan to pay for the MRI of the brain. You say that you would like reconsideration because this
service is not specific to a a place of service. The Plan denied your request. The Plan says the member was
registered inpatient on the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 70551 is not supported in the record. Specifically, the record indicates that the member
was registered inpatient on the billed date of service. This means that it is inappropriate to bill this service with
an outpatient place of service code. Based on this information, we decided that Medicare rules for coverage of
the MRI of the brain have not been met. Therefore, we decided that the Plan does not have to pay for MRI of
the brain (70551).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says this service is not urgent/emergent and is available in-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
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 service is medically necessary. The Plan denied
your request. The Plan says benefits can be provided at a lower level of care.

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 complexity of the patient's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care and the patient
does not require an intensive inpatient rehabilitation therapy program.

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. Specifically, the member can benefit from a lower
level of care. This means the IRF admission is not medically necessary or reasonable. Therefore, we decided
that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit.

You asked the Plan to pay for the domiciliary or rest home visit (99337). You say that the claim was timely but due to a system glitch it did not process correctly. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the domiciliary or rest home visit (99337) was not filed. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre CGM sensor.

You asked the Plan to pre-approve a CGM sensor. You say that the requested item is necessary because the enrollee does not want to stick a finger multiple times per day. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre CGM sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visits (99213).

You asked the Plan to waive the copayment for the specialist office visits. You say that you should not be charged a copayment because you received unsatisfactory care from your provider. The Plan denied your request. The Plan says the copayment 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 $35 copayment for each specialist visit.

You have been asked to pay a total of $105 ($35 copayment x 2 visits = $105) for the specialist office visits. These services fall within the Physician/Practitioner services, including doctor's office visits 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 specialist office visits (99213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the surgical extraction (D7210 x 2), the
extraction of residual tooth roots (D7250 x 2), the initial fifteen minutes of conscious sedation (D9239), and the
additional fifteen minutes of conscious sedation (D9243).

You asked the Plan to pay the full amount for the dental services. You say that a plan representative advised
that the plan would pay $500 for the services and pay for your cleanings and fillings. You say that you were
also advised that you should get the dental rider. You say that you misunderstood that the provider would
charge you over what you had to pay. You also say that you cannot afford to pay this bill. The Plan denied your
request. The Plan says the provider in this case is out of network. The Plan says that there is a 50% coinsurance
for the extractions and sedation. The Plan also says that says that you may still be billed by an out-of-network
provider for any amount greater than the MAC payment made by the plan to the 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, there is a 50% coinsurance for
extractions and conscious sedation. Additionally, the Evidence of Coverage clearly states that out-of-network
providers may bill you for any amount greater than the MAC payment made by the plan to the provider.
Therefore, we decided that the Plan does not have to pay the full amount for the surgical extraction (D7210 x
2), the extraction of residual tooth roots (D7250 x 2), the initial fifteen minutes of conscious sedation (D9239),
and the additional fifteen minutes of conscious sedation (D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet light therapy system panel for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show psoriasis.

The Plan must follow Medicare rules. Medicare rules say that ultraviolet cabinets are covered for selected patients with generalized intractable psoriasis.

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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare rules say that ultraviolet cabinets are covered for selected patients with generalized intractable psoriasis. In this case, the medical records do not indicate that the enrollee has generalized intractable psoriasis. Therefore, the criteria for Medicare coverage of a home ultraviolet light therapy system panel are not satisfied and coverage cannot be recommended.

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light therapy system panel for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of cataract with insertion of lens.

You asked the Plan to waive the copayment for removal of cataract with insertion of lens. You say that the plan is responsible for paying. The Plan denied your request. The Plan says the correct cost share has been applied to the claim.

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 $335 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Center.

You have been asked to pay a $335 copayment for the removal of cataract with insertion of lens. This procedure falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Center 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 removal of cataract with insertion of lens.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for genicular nerve radiofrequency ablation procedure (64624).

You asked the Plan to pay for the radiofrequency ablation procedure. You say that the procedure is effective for pain relief. Please reprocess claim. The Plan denied your request. The Plan says genicular nerve radiofrequency ablation for the knee is considered experimental and/or investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pay for genicular nerve radiofrequency ablation procedure (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal evaluation.

You asked the Plan to pay for these services. You say that you would like the services to be covered. The Plan denied your request. The Plan says the services are 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, 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 the periodontal evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0651) and pneumatic appliance (E0667).

You asked the Plan to pay for intermittent limb compression device and pneumatic appliance. You say that the requested items are medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the provided diagnosis (ICD-10 diagnosis code I87.2).

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.

The file shows that the enrollee has chronic venous insufficiency. The file does not show that the enrollee has chronic venous insufficiency with venous stasis ulcers. Additionally, accessories (such as E0667) related to pneumatic compression devices (PCDs) are eligible for reimbursement only when the related base PCD meets the applicable coverage criteria. If the base PCD is not covered, the related accessories are not eligible for reimbursement. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device (E0651) and pneumatic appliance (E0667).