Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit on November 11, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that the urgent care was full so you had to go and feel that you should only owe a n urgent care copayment. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 for an ER visit on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80307 and Healthcare Common Procedural Coding System (HCPCS) code G0480 remain 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 the denied codes is: CPT 80307: Drug tests(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. HCPCS G0480: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no documentation of provider concern for drug abuse/misuse. There is no evidence that UDS results were reviewed prior to ordering the UDT. The UDT was not tailored to the enrollee's addictions, medications or UDS results. Therefore, the documentation does not support that the provided UDS or confirmatory UDT were medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound provided on December 12, 2019.You asked the Plan to waive the copayment forthe ultrasound. You say that since mammograms are a preventive service, ultrasounds performed with them should be covered in full.The Plan denied your request. The Plan says the copayment applied correctly.The rules say aplan 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 copayment for outpatient diagnostic tests provided by an in-network specialty physician.You have been asked to pay a $20 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a diagnostic test. 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 ultrasound provided on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a coronectomy (D7251) for tooth # 17. You asked the Plan to pre-approve a coronectomy. You say that the services have not been performed. You say that there is a cyst on tooth # 17. The Plan denied your request. The Plan says that the coronectomy is not medically necessary at this time. The Plan must follow Medicare rules. The rules say that Medicare 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 information regarding 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. Therefore the plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve a coronectomy (D7251) for tooth # 17.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDX test provided to the enrollee on November 14, 2018.
You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. The Plan says these are not covered charges.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).
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 test have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDX test provided to the enrollee on November 14, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Lite test strips (A4253).You asked the Plan to pre-approveFreestyle Lite test strips. You say that the items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as theenrollee retains access to all medically necessary items (including non-preferred brands). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle Lite test strips have not been met. Specifically, medical records were not provided. Without this documentation medical necessity for the specific brand requested is not able to be established.Therefore, we decided that the Plan does not have to pre-approveFreestyle Lite test strips (A4253).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Synvisc-One. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210), a gingivectomy or gingivoplasty (D4211), and a consultation including an oral evaluation (D9310) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that your dentist advised that he could not do the extraction. You say that it is because you have osteoporosis. You also say that you need to have the tooth extracted by an oral surgeon and a flap placement to avoid sinus drainage. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist. The Plan also says that dental services that you receive from an oral surgeon 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 dental services are not covered when you receive them from an oral surgeon. The Evidence of Coverage clearly states that dental services must be performed by a participating general dentist in order to be covered. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210), a gingivectomy or gingivoplasty (D4211), and a consultation including an oral evaluation (D9310) to be provided by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided on October 14, 2018 to October 20, 2018 by an out of network (OON) provider.You asked the Plan to pay forhome health services. You say that these services should not require prior approval.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 forhome health services provided on October 14, 2018 to October 20, 2018 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom abutments (D6057) and abutment supported crowns (D6059) for teeth # 28 and 30.
You asked the Plan to pre-approve the dental services. You say that you need a crown in order to eat properly. The Plan denied your request. The Plan says custom abutments and abutment supported crowns are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom abutments (D6057) and abutment supported crowns (D6059) for teeth # 28 and 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKetamine treatments.You asked the Plan to pre-approvethese services. You say that the services are necessary for chronic pain.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have chronic neck spine pain after spinal surgery. The requested ketamine treatment is considered experimental/investigational for this condition. Thetreatment is not FDA-approved for your condition. The services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof these services have not been met.Therefore, we decided that the Plan does not have to pre-approveKetamine treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator from the facility.
You asked the Plan to pre-approve an oxygen concentrator. You say that you need an oxygen concentrator. The Plan denied your request. The Plan says records do not say that your oxygen level is 88% or less.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a custom-fitted mandibular sleep apnea appliance from provider.You asked the Plan to pre-approve the custom-fitted mandibular sleep apnea appliance from American Sleep Dentistry, LLC.. You say that  The Plan denied your request. The Plan says that the request is for a custom-fitted mandibular sleep apnea appliance provided by an out-of-network Durable Medical Equipment (DME) provider. The Plan says that DME services can be provided by a participating provider.The Plan must follow Medicare rules. The rules say that Medicare 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 information regarding their decision to deny your request. The Plan has not provided us information about which participating providers can supply the device being requested. The Plan has, therefore, not substantiated their denial reason by proving that the care is available in-network.Therefore, we decided that the Plan has to pre-approve a custom-fitted mandibular sleep apnea appliance from provider.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 10, 2019 and billed under code 23071.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says CPT code 23071 was not the most appropriate service performed for the place of service 11; we find that Medicare rule for payment for CPT code has not been met. The Plan states a correct claim would be reviewed if submitted. 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, code 23071 and POS code 11 have created an error in billed preventing payment. The Plan states a corrected claim would be reviewed if submitted. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 10, 2019 and billed under code 23071.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that the enrollee has severe bruxism. You also say that an occlusal guard is needed to reduce the stress wear on the enrollee's teeth and pain in the jaw. The Plan denied your request. The Plan says this service is not covered by 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 the occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 29, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that the doctor provided no service and you should not be responsible for the copayment. 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 $35 copayment for each Medicare-covered visit with an in-network specialist. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen to discuss the CPAP machine versus alternatives.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 specialist office visit provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 19, 2019 and billed under codes G0480 and 80307.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the medical records provided do not support the services billed. The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat the enrollee as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on August 19, 2019 and billed under codes G0480 and 80307.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213).
You asked the Plan to pre-approve the dental item. You say that the enrollee accidentally threw away her partial denture. You also say that the enrollee is having trouble eating without teeth. The Plan denied your request. The Plan says partial dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 and dentures are a covered service, the frequency limit of once every 5 years has been reached. The record shows that the Plan previously paid for an upper partial denture that you received on March 20, 2018. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 7, 2019 through May 7, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says S codes are not payable by Medicare.
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 code 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 January 7, 2019 through May 7, 2019.