Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvethe excision of excessive skin and fat of the abdomen and mons.You asked the Plan to pre-approvethe excision of excessive skin and fat of the abdomen and mons. You say that this should be covered.The Plan denied your request. The Plan says that this is cosmetic.The Plan follows Medicare rules. Medicare rules say that when an abdominal lipectomy/panniculectomy is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, and the above symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive.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 excision of excessive skin and fat of the abdomen and mons. Our reviewer says that the requested services are medically necessary. Our physician reviewer found the submitted records show evidence of chronic intertrigal dermatitis which has been present for at least 3 months and has been refractory to usual standard dermatologic treatment.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 excision of excessive skin and fat of the abdomen and mons have been met.Therefore, we decided that the Plan has to pre-approvethe excision of excessive skin and fat of the abdomen and mons.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 a pneumatic compression device (E0676) and a neuromuscular stimulator (E0745). You asked the Plan to pay for a pneumatic compression device. You say that the devices were required after surgery. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery and the neuromuscular stimulator is approved only when muscle atrophy is present or to aid with walking in patients with a spinal cord injury. The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The neuromuscular stimulator is approved only when muscle atrophy is present or to aid with walking in patients with a spinal cord injury. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD and neuromuscular stimulator 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 a pneumatic compression device (E0676) and a neuromuscular stimulator (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy services provided on October 4, 2019 to October 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forpsychotherapy services. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior 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 forpsychotherapy services provided on October 4, 2019 to October 28, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth # 4.
You asked the Plan to pre-approve the dental service. You say that a crown is needed for tooth # 4 due to extensive build up with only buccal and mesial wall existing. The Plan denied your request. The Plan says that the tooth does not have significant breakdown.
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 dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation shows there is significant breakdown of the coronal surfaces of tooth # 4. The reviewer found that placement of a crown to restore the tooth to adequate masticatory function meets the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth # 4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forintermittent limb compression device (E0675).You asked the Plan to pay forintermittent limb compression device. You say that you need the device to increase blood flow to your upper extremities.The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for any indication.The Plan follows Medicare rules. The rules state that Medicare does not covers pneumatic devices coded by E0675. Under Medicare guidelines, your request is not a covered benefit because Medicare never covers this device.Therefore, we decided that the Plan does not have to pay forintermittent limb compression device (E0675)
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Psychotherapy services (90834, 90837).You asked the Plan to pre-approvethe psychotherapy services. You say that the services are medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.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 psychotherapy services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found this patient is not showing any symptoms of suicidal ideation, homicidal ideation, psychosis, severe mood symptoms, substance abuse, physical aggression or self-injurious behavior. The number of visits requested are excessive.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the psychotherapy services have not been met.Therefore, we decided that the Plan does not have to pre-approvePsychotherapy services (90834, 90837)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on November 12, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you would told you would not owe anything. 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 a $75 copayment for each advanced imaging service (e.g., MRI, CT and PET scan, nuclear medicine, and stress tests). You have been asked to pay a $75 copayment for the CT scan. The CT scan 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 CT scan provided by on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that the claim should be paid.The Plan denied your request. The Plan says are noncovered because they are a nonreusable supply item.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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-approvecompression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services coded 90792 provided on April 30, 2019.
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are missing an appropriate primary, first listed diagnosis.
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 90792 is psychiatric diagnostic evaluation with medical services. We find that CPT code 90792 is not supported in the medical record. Specifically, this code was not billed with the appropriate primary, first listed or principal diagnosis. A secondary diagnosis cannot be used as the only diagnosis on the claim. Based on this information, we decided that Medicare rules for coverage of the psychiatric diagnostic evaluation with medical services have not been met. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services coded 90792 provided on April 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from June 27, 2019 through July 1, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that the provider did not bill for the last day and you are not stuck with the entire bill.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on June 27, 2019 and discharged on July 1, 2019. You were asked to pay a $325 copayment per day from June 27, 2019 through June 30, 2019, days 1-4 of your inpatient hospital care. You were discharged on July 1, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-5. 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 inpatient hospital care from June 27, 2019 through July 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued outpatient mental health care visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve outpatient mental health visits. You say that you were approved to see this provider in 2019 and want to continue care. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network Provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 outpatient mental health visits. Our reviewer says that you do not meet the Medicare criteria for continuity of care with this out-of-network provider. Our physician reviewer found based on the records, it is noted that you saw this provider on January 28, 2020 which was not authorized. The Plan has stated that the only reasons for seeing an out-of-network provider are an urgent/emergent condition or if a therapist is not available in-network. You condition is not considered to be an urgent/emergent condition. The provider indicated that there was no concern for risk. There is an in-network provider located in your area which is accepting new patients. You can be safely seen by an in-network therapist who is credentialed and maintained by the Plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient mental health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued outpatient mental health care visits to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electroencephalographic testing provided on May 15, 2019.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says the documentation does not corroborate the billed services.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 95951 is monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours.We asked our coding 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 testing services. Our reviewer foundthat themedical records provided do not include documentation to validate the total time spent providing the billed service. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Therefore,this service cannot be verified.We looked at this coder'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe electroencephalographic testing provided to the enrolleeon May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 7, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal exam provided to the enrollee on December 6, 2019.You asked the Plan to pay forthe periodontal services. You say that you were told the services would be covered.The Plan denied your request. The Plan says the 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.Although the Plan offers a dental benefit in excess of Medicare coverage, the provided services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal exam provided to the enrollee on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for CPAP device (CPT Code E0601) provided on December 14, 2019.
You asked the Plan to waive the coinsurance for the DME. 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.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a CPAP device on December 14, 2019. You are asked to pay 20% coinsurance for the DME. 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 CPAP device (CPT Code E0601) provided on December 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from October 3, 2019 through October 11, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that there is no additional copayment if the hospital stays are within 20 days of each other. You say that you should only have one copayment.The Plandenied your request. The Plan says the copayment 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 Planclearly says that you must pay $290 per day, for days 1-5 and $0 per day,for days 6-90 for each in-network, medically necessary covered inpatient stay.Your contract with the Plan clearly says thatyour inpatient benefits will begin on day one each time you are admitted within or to a specific facility type. A transfer within or to a facility including Inpatient Rehabilitation facilities, Long Term Acute Care (LTAC) facilities, Inpatient Acute Care facilities, and Inpatient Psychiatric facilities, is considered a new admission.You have been asked to pay a $1,450 copayment for the inpatient stay. ($290/day x first 5 days = $1,450). The inpatient stay falls within the "Inpatient hospital care" 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 forthe inpatient stay provided from October 3, 2019 through October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided on January 28, 2020.You asked the Plan to pay for the chiropractic treatment. You say that the booklet you received from the Plan says you have coverage for chiropractic care. The Plan denied your request. The Plan says you must receive care from in-network providers with theexception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 chiropractic services.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 chiropractic treatment provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis, periodic oral evaluation, and bitewings provided on December 19, 2019.You asked the Plan to pay forthe prophylaxis, periodic oral evaluation, and bitewings. You say that you have seen this provider in the past and the Plan has paid for services. You also say that you contacted your dental office who told you at no time did they drop their acceptance of Medicare.The Plan denied your request. The Plan says this provider has affirmatively opted out of Medicare and was no longer a participating provider with your dental plan.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe prophylaxis, periodic oral evaluation, and bitewings provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the motorized scooter provided on June 12, 2019 from an out-of-network provider.
You asked the Plan to pay for the motorized scooter. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 motorized scooter provided on June 12, 2019 from an out-of-network provider.