Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).

You asked the Plan to pre-approve dentures. You say that you need to replace your dentures following a car accident. You say that you have not been able to eat regularly after the accident. You say that you can only drink smoothies and shakes. The Plan denied your request. The Plan says the benefit for dentures is currently exhausted.

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 benefit for dentures is limited to once every 60 months. The records show that you received coverage for dentures on December 19, 2016, and on February 17, 2017. This means that your request for coverage of dentures now exceeds your benefit allowance. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from August 1, 2020, to August 2, 2020.

You asked the Plan to waive the copayment for inpatient stay. You say that the hospital needed to hold the enrollee until he was safe to be discharged. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $350 copayment per day for days 1 to 5 for inpatient stay. This inpatient stay lasted 1 day, resulting in a copayment amount of $350. 

The enrollee has been asked to pay $350 copayment per day for days 1 to 5 for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from August 1, 2020, to August 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for set up of portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided June 17, 2020.

You asked the Plan to pay for the portable x-ray services. You say that the billing documentations and medical records provided support that the services were performed at the SNF. The Plan denied your request. The Plan says when the member is under an approved SNF stay, the provider should seek reimbursement from the SNF directly.

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, when the member is under an approved SNF stay, the provider should seek reimbursement from the SNF directly. Based on this information, we decided that Medicare rules for coverage of the portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for set up of portable x-ray equipment (Q0092) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) provided June 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 14, 2020, by an out-of network
(OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
You say that you provided these services in good faith. The Plan denied your request. The Plan says prior
authorization was not obtained. The Plan says that the referring nursing facility is out-of-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 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 had network providers
available who could have provided 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 physician services provided on May 14, 2020, by
an out-of-network (OON) 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 you need more care. The Plan denied your request. The Plan says the enrollee's needs can be met in 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 29, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you never received any services on January 29, 2020. 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 $45 copayment for routine radiology. 

The medical records show that you received an ultrasound on January 29, 2020. Therefore, you are responsible to pay the $45 copayment. 

You have been asked to pay a $45 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on January 29, 2020.
Appeal type: Supplemental Benefit
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 March 5, 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 had network providers available who could have provided 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 March 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for placement of skin and bone flap with microvascular connection (20969) provided on March 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the surgical procedure. You say that please review all attached medical reports to support the services billed for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided 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 placement of skin and bone flap with microvascular connection (20969) provided on March 9, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8mg Ondansetron Tablets.

You asked the Plan to pre-approve the Ondansetron. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not a covered benefit under Medicare Part B.

The Plan must follow Medicare rules. Medicare rules say that the oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Ondansetron have not been met. Specifically, the record states that the requested drugs will not be used as a full replacement for IV anti-nausea medicines. Therefore, we decided that the Plan does not have to pre-approve 8mg Ondansetron Tablets.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-share for the fluoroscopic guidance for needle placement (77002). We decided that the Plan does not have to reduce the cost-share for the Magnetic Resonance Imaging (MRI) of the lower extremity (73722) and the Gadobutrol injection (A9585).

You asked the Plan to reduce the cost-share for the radiological services. You say that you cannot afford this cost-sharing responsibility and last year the diagnostic radiology coinsurance was only 20%. The Plan says that radiological imaging services have a $155 copayment per service.

We decided that the Plan has to reduce the cost-share for the fluoroscopic guidance for needle placement (77002).

The Plan has asked you to pay a $127.81 copayment for the fluoroscopic guidance for needle placement (77002). The Plan's allowed amount for this service is $127.81, and they applied the $155 copayment for radiological diagnostic services other than x-rays. Because the allowed amount for this service is less than the copayment, you do not have to pay the full $155 cost. However, fluoroscopic guidance for needle placement (billing code 77002) uses an x-ray and is otherwise referred to as needle localization by x-ray. Therefore, the $30 copayment for x-ray services should apply rather than the $155 copayment for radiological diagnostic services other than x-rays. Therefore, we decided that the Plan has to reduce the cost-share for the fluoroscopic guidance for needle placement (77002) from $127.81 to $30.

We also decided that the Plan does not have to reduce the cost-share for the MRI of the lower extremity (73722) and the Gadobutrol injection (A9585).

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 $155 copayment for radiological diagnostic services other than x-rays and 20% coinsurance for medical supplies including dyes or chemical agents used in certain diagnostic procedures. You have been asked to pay $155 for the MRI and $0.07 for the Gadobutrol injection. The Plan's allowed amount for the Gadobutrol is $0.37 ($0.37 x 20% = $0.07). Therefore, we decided that the Plan does not have to reduce the cost-share for the MRI of the lower extremity (73722) or the Gadobutrol injection (A9585).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator.

You asked the Plan to pay for the oxygen concentrator. You say that this service is medically necessary for your condition. The Plan denied your request. The Plan says a portable oxygen concentrator that you purchase is not eligible for coverage.

The Plan must follow Medicare rules. Medicare rules say that the Plan may not pay for oxygen purchased on or after June 1, 1989.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider.

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 had network providers available who could have provided 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 you by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture adjustment (D5660).

You asked the Plan to pay for the dental service. You say that the claim was denied because you maxed out your $1,000. You say that you were informed that you got a free pull and cleaning yet it was taken out of the $1,000. You also say that this is misleading and not fair. The Plan denied your request. The Plan says there is an annual maximum allowance of $1,000 per year. The Plan says that the maximum allowance has been exceeded.

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 annual maximum allowance of $1,000 has been exceeded. The record shows that the Plan paid $165 for dental services that you received, $407 for dental services that you received, $330 for dental services that you received, and $98 for dental services that you received. The Evidence of Coverage clearly states that you pay 100% of charges beyond the $1,000 allowance. Therefore, we decided that the Plan does not have to pay for the denture adjustment (D5660).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95937, 95955, and 95940 are not supported.

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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95940 is continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure).

We find that CPT codes 95937, 95955, and 95940 are not supported in the medical record. Specifically, the operative report does not contain documentation of neuromuscular junction testing for each nerve to support code 95937. There is no documentation of an EEG during nonintracranial surgery to support code 95955. There is no documentation of continuous intraoperative neurophysiology monitoring in the operating room for each 15 minutes to support code 95940. 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 for the testing services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided 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. The Plan denied your request. The Plan says the services provided 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 had network providers available who could have provided 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 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.

The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the services rendered to.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided to you by an out-of-network provider.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says out-of-network services are not covered.

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 had network providers available who could have provided 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 hearing aids provided to you by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an OON provider.

You asked the Plan to pay for the dental services. You say that you were able to find an in-network dentist that was available due to COVID-19. The Plan denied your request. The Plan says these services were rendered by an OON 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, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the dental services provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation.

You asked the Plan to pay for the comprehensive oral evaluation. You say that this service is necessary for any dental appointment. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, you are limited to either one periodontal exam or one comprehensive oral evaluation every three years. The record shows that you received a comprehensive oral evaluation, and your exams benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation.