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

We decided that the Plan does not have to pay forneuromonitoring services (95999) provided June 23, 2020.You asked the Plan to pay forthe neuromonitoring services. You say that the service was medically necessary.The Plan denied your request. The Plan says this code is not eligible for separate payment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the medical record. Specifically, payment for this service is bundled with the primary procedure. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay forneuromonitoring services (95999) provided June 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveHydrocodone-Acetamin 10-325mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare says Part B programs can only provide limited benefits for prescription drugs.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 Plandoes not haveto pre-approveHydrocodone-Acetamin 10-325mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.
You asked the Plan to pre-approve these services. You say that the provider has been highly recommended. The Plan denied your request. The Plan says the services are available from network providers.
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 items/services at issue in this appeal. The Plan confirmed that they have in-network female urologists available to provide your care. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the gastric emptying imaging studies you
had on July 21, 2020, and July 23, 2020.
You asked the Plan to waive the copayment for the gastric emptying imaging studies. You say that you were
not aware of this copayment. You said that you did know not it would be a big cost and it ended up that there
was nothing wrong with your stomach. The Plan denied your request. The Plan says you were charged these
copayments 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 $150
copayment for complex diagnostic radiology services.
You have been asked to pay a $150 copayment for the gastric emptying imaging studies. The gastric emptying
imaging studies fall within the complex diagnostic 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 the gastric emptying imaging studies you had on July 21, 2020, and
July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 18, 19, 20, 25 and 28.

You asked the Plan to pre-approve the dental services. You say that the enrollee presented with multiple carious lesions and missing teeth. You say that core build up is necessary to restore decayed areas of teeth # 18, 19, 25 and 28.The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that if a dental item or service is not listed in the benefit chart then it 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, 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 core build up (D2950) for teeth # 18, 19, 20, 25 and 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a clinical crown lengthening (D4249) and retreatment of
previous root canal therapy (D3347).
You asked the Plan to pre-approve the clinical crown lengthening and retreatment of previous root canal
therapy. The Plan denied your request. The Plan says these services are not covered under the enrollee's plan.
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
clinical crown lengthening (D4249) and retreatment of previous root canal therapy (D3347).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forDME delivery, set up, and/or dispensing service component of another HCPCS code identified with code A9901 received on July 15, 2020.You asked the Plan to pay forDME delivery, set up, and/or dispensing service component of another HCPCS code. You say that you disagree with the plan's denial.The Plan denied your request. The Plan says the services billed are not covered.The Plan must follow Medicare rules. Medicare rules say that delivery and service costs are ordinarily assumed to have been taken into account by suppliers in setting the prices they charge for covered items and services.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of DME delivery, set up, and/or dispensing service component of another HCPCS code have not been met.Therefore, we decided that the Plan does not have to pay forDME delivery, set up, and/or dispensing service component of another HCPCS code identified with code A9901 received on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on June 23, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the increase in charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on June 23, 2020. The allowed amount is $125 and 20% of that is $25. You have been asked to pay the total coinsurance amount of $25 for a Medicare Part B drug. A Medicare Part B drug 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 a Medicare Part B drug provided on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee scooter (E0118) provided on July 31, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for a knee scooter. You say that you were told you would be reimbursed for this
item. The Plan denied your request. The Plan says this was 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 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 knee scooter (E0118) provided on July 31,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on March 22, 2019.
You asked the Plan to pay for surgical services. You say that your records indicate that the claim was filed timely. The Plan denied your request. The Plan says rules for payment have not been met.
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 surgical services was not filed until July 30, 2020. 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 surgical services provided on March 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tab 30mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a benefit exclusion.
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 Otezla tab 30mg for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve diabetic shoes. You say that you would like approval for this provider. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAjovy for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plandenied your request. The Plan says that this is not covered under Part B.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-approveAjovy for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided.

You asked the Plan to pay for the inpatient hospital care. You say that the services provided were medically necessary.The Plan denied your request. The Plan says the services provided were unauthorized inpatient post-stabilization services.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 inpatient hospital care. Our reviewer says that the inpatient care was not medically necessary or reasonable. Our physician reviewer found the enrollee was stable and appropriate for ambulance transport with monitoring to a Plan facility for continued hospital services. The review has determined that  the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

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 inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran electrocardiogram (93010) and an emergency room visit (99285) on July 16, 2019.You asked the Plan to pay foran electrocardiogram and an emergency room visit. You say that the claim was previously filed within timely filing guidelines.The Plan denied your request. The Plan says rules for payment have not been met.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 an electrocardiogram and an emergency room visit was not filed until August 13, 2020. 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 foran electrocardiogram (93010) and an emergency room visit (99285) on July 16, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required,
crown, four gingival irrigations, and scaling in presence of generalized moderate or severe gingival
inflammation.
You asked the Plan to pre-approve a core buildup, crown, gingival irrigations, and scaling. You say that you
have already paid for the services. The Plan denied your request. The Plan says these services are not covered
under your plan.
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
core buildup, including any pins when required, crown, four gingival irrigations, and scaling in presence of
generalized moderate or severe gingival inflammation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on April 30, 220,
through June 2, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because
this service is not durable medical equipment and was not delivered to the member's home. The Plan denied
your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328)
provided on April 30, 220, through June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the insertion of a catheter into a dialysis circuit provided.

You asked the Plan to waive the copayment for the insertion of a catheter into a dialysis circuit. You say that you disagree with the charges because you did what the hematologist wanted and cannot afford the charges.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 $160 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You have been asked to pay a $160 copayment for the insertion of a catheter into a dialysis circuit. The insertion of a catheter into a dialysis circuit 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 c opayment for the insertion of a catheter into a dialysis circuit provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent physician services provided on May 18, 2020 by an out of network (OON) provider.You asked the Plan to pay fornon-emergency physician services. You say that you would like this bill paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.Medicare rules say thatplans 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. The facility that provided theseservices is not considered an urgent care center; therefore, these services were not emergency and could have been provided in-network. 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 non-emergent physician services provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvea crown for tooth #3.You asked the Plan to pre-approvethe crown. You say that this service is necessary.The Plan denied your request. The Plan says that this service is not medically necessary.The Plan must follow Medicare rules. The rules say thatMedicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us informationregarding their decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial of payment in this case.Therefore, we decidedthat the Plan has to pre-approvea crown for tooth #3.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 Planhas 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital services rendered from January 22, 2020 to January 25, 2020.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 was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21.We looked at the file and Medicare rules. The file shows that the inpatient services were billed with POS code 22 for outpatient hospital. Based on this information, we decided thatMedicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital services rendered from January 22, 2020 to January 25, 2020