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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on March 9, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you were not aware that the x-rays were only covered once every three years. You also say that the provider was supposed to contact the Plan, but did not because you would not have had the x-rays done. The Plan denied your request. The Plan says these services exceed the frequency limitation in your benefit plan. The Plan also says that you did not contact the Plan prior to the services being rendered to confirm your benefits or limitations.
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, comprehensive oral evaluations and complete series of intraoral x-rays are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on February 14, 2019 and your comprehensive oral evaluation and complete series of intraoral x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on March 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on November 6, 2019 to December 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient mental health services. You say that you think that these services should be covered. The Plan denied your request. The Plan says no prior authorization was obtained 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 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 outpatient mental health services provided on November 6, 2019 to December 18, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT)
Colonography (74263) provided April 18, 2019.
You asked the Plan to waive the copayment for the Colonography. You say that the copayment should be
waived since the original colonoscopy was a preventative service and could not be completed. The Plan denied
your request. The Plan says the CT colonography is a separate service from the colonoscopy and therefore the
correct copayment was applied.
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 $275
copayment for Diagnostic Radiology.
You have been asked to pay the Medicare allowed amount of $129.89 for the Colonography. The
Colonography falls within the Diagnostic Radiology benefit category. In this case the allowable amount is less
than the copayment stipulated in the plan contract. 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 a
Computed Tomography (CT) Colonography (74263) provided April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dexamethasone sodium phosphate and triamcinolone acetonide provided on March 2, 2020.
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the drugs were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drugs. Our reviewer says that the requested drugs were not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that first line treatment for allergic rhinitis is corticosteroid nasal spray and oral antihistamines, not injected corticosteroids. There was no documented contraindications to first line treatment options, nor any explanation why using a higher risk treatment method was best for this enrollee. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pay for the dexamethasone sodium phosphate and triamcinolone acetonide provided on March 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 6, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the place of service code billed with this service is correct. The Plan denied your request. The Plan says the service was billed with an outpatient place of service and the service date falls between the admission and discharge date of an inpatient confinement.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Specifically, the record indicates that the member was in an inpatient stay on this date of service. This service was billed with an outpatient place of service code. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopath services provided on December 4, 2019 through December 16, 2019. 
 
You asked the Plan to pay for the naturopath services. You say that you would like reconsideration because you believed physical therapy would have been covered. The Plan denied your request. The Plan says naturopathy services were not a covered benefit in 2019. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for naturopath services provided on December 4, 2019 through December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on February 24, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and approved for payment. 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 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 an outpatient visit provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim processed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 lab work provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a raised toilet seat or a transport wheelchair
purchased on November 30, 2019.
You asked the Plan to reimburse you for the raised toilet seat and the transport wheelchair. You say that the
raised toilet seat and transport wheelchair were necessary for your recovery. The Plan denied your request. The
Plan says the raised toilet seat is not a covered benefit and the supplier is not Medicare certified.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered
because they are not primarily medical in nature. Medicare rules state that no Medicare payment may be made
to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment.
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Also the items at issue in this appeal were provided by a provider not certified by Medicare. Therefore,
we decided that the Plan does not have to reimburse you for the raised toilet seat or the transport wheelchair
purchased on November 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete denture - mandibular (D5120) and complete denture - maxillary (D5110) provided on November 4, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Review of the file show that you received complete denture - mandibular (D5120) and complete denture - maxillary (D5110) provided on November 4, 2019. You were asked to pay a $195 copayment per denture. Your total cost share responsibility is $390 ($195 + $195 = $390). Your EOC states, enrollees must pay a $25-$195 copayment for Prosthodontics and Oral Surgery. Therefore, we decided that the Plan does not have to pay for complete denture - mandibular (D5120) and complete denture - maxillary (D5110) provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 10, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the lab code billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the chemotherapy injection provided on December 15, 2019. 
 
You asked the Plan to reduce the coinsurance for the chemotherapy injection. You say that you feel you should continue to pay the previous coinsurance. You say the increase of the coinsurance is financial hardship. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B Chemotherapy drugs, associated administration services and all other Medicare Part B drugs.  
 
You have been asked to pay $1,840.94 which is 20% of the allowed amount for the chemotherapy injection. The allowed amount is $9,204.72. ($9,204.72 x 20% = $1,840.94). The chemotherapy injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for the chemotherapy injection provided on December 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services 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. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. In this case, you are mostly moderate/minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on September 30, 2019. 
 
You asked the Plan to waive the copayment for wound debridement. You say that you disagree with the facility charges and feel that you should only owe a specialist 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 $125 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $125 copayment for wound debridement. Wound debridement falls within the outpatient surgery and other medical 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 copayment for wound debridement provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress.
You asked the Plan to pre-approve a semi-electric hospital bed (E0260) and mattress (E0184). You say that the enrollee needs a semi-electric hospital bed and mattress to help aid in recovery post-surgery and incisional healing. The Plan denied your request. The Plan says the supplied documentation does not indicate that the enrollee requires frequent and immediate need for a change in body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed (E0260) and mattress (E0184). Our reviewer says that the semi-electric hospital bed and mattress are not medically necessary. Our physician reviewer found the enrollee's condition requires positioning of the body in ways not feasible in an ordinary bed as the enrollee has attempted positioning with pillows that has not helped reduce pain. The enrollee's medical conditions do not support requiring a frequent or immediate need for change in body position. The documentation states the enrollee needs frequent positioning to alleviate pain and provide safety but there is no discussion of enrollee's pain levels. The enrollee was noted to be feeling better and the document notes no chest pain. There is no discussion that the enrollee was unsafe in an ordinary bed and the enrollee does not require special attachments that cannot be fixed and used on an ordinary bed. The semi-electric hospital bed is not medically necessary for this patient per Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820). The Group 1 mattress is not medically necessary. The enrollee is not completely immobile. The enrollee can make changes in body position to alleviate pressure and the enrollee does not have a pressure ulcer on the trunk or pelvis. The Group 1 mattress is not medically necessary per Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 1 (L33830). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed (E0260) and mattress (E0184) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint steroid injections.
You asked the Plan to pre-approve SI joint injections. You say that this procedure alleviates your pain and helps you. The Plan denied your request. The Plan says the denial of authorization for these injections is correct, because there is no documentation of the amount of pain relieved by previous injection therapy.
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 SI joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation submitted is not clear that the injections are effective as there is no indication that prior injections have caused significant improvement in pain and function. The documentation does not show that you have failed all conservative treatment options as the most recent notes indicate you are to continue with physical therapy. Recent office visits were virtual, without a physical examination, therefore it is unclear whether the SI joint steroid injections are being requested in a setting appropriate to your medical needs and condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on February 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON psychotherapy services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on February 26, 2020 by an out of network (OON) provider.