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

We decided that the Plan does not have to pay formonitoring services provided to the enrollee on July 19, 2019 and billed under code95951 and 95819.You asked the Plan to pay forthis claim. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met.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 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 this claim. Our physician reviewer found that the National Correct Coding Initiative (NCCI) Policy Manual, chapter I states: Physicians must report services correctly. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. The records do not support the services billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay formonitoring services provided to the enrollee on July 19, 2019 and billed under code 95951 and 95819.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Methocarbamol 500 mg tablet.You asked the Plan to pre-approvethis medication.You say that you are requesting reconsideration of the Plan's denial as you have been utilizing this medication with successful control of symptoms.The Plan denied your request. The Plan says this medication is not a covered benefit under your policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Methocarbamol 500 mg tablet.Benefits for this medication.may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray (72110) provided September 26, 2019. You asked the Plan to waive the copayment for the x-ray. You say that thecopayment should be waived.The Plan denied your request. The Plan says 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 $95 copay for Radiology Services. You have been asked to pay a $95 copay for the x-ray. The x-ray falls within the Radiology Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran X-ray (72110) provided September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, (E2311) to be provided.You asked the Plan to pre-approve power wheelchair accessory. You say that please reconsider this code E2311 which is needed in order to operate a multi power wheelchair and allow the enrollee to be able to move the elevating lets and power tilt system with the joystick.The Plan denied your request. The Plan says upgraded electronics cannot be covered per Medicare rules.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair accessory have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, (E2311) to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve dermatology services. You say that you would like approval t see the physician.The Plan denied your request. The Plan says there are in-network providers available for the services that are being requested.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providersonly 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from July 2, 2019 to July 11, 2019 by out of network provider.You asked the Plan to pay forchiropractic services. You say that this provider respects your religious beliefs and bridges and language barriers that may occur, and other providers in your area have not shown this level of care and respect.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and you could have been treated by an in-network chiropractor.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 forthe medical services provided from July 2, 2019 to July 11, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the requested services are medically 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for chronic obstructive pulmonary disease (COPD) and an ophthalmologic issue. The enrollee is not intubated, but is using supplemental oxygen and nighttime noninvasive positive-pressure ventilation (NiPPV). As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCombination sit to stand frame system (E0637).You asked the Plan to pre-approvethe combination sit to stand table system. You say that it is your understanding that Medicare does not cover this item but to your knowledge your supplemental insurance will cover if you pass certain requirements.The Plan denied your request. The Plan says this item is considered a convenience item and is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveCombination sit to stand frame system (E0637).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown lengthening (D4249) provided on September 25, 2019 by the out of network provider.You asked the Plan to pay forthe dental service. You say that  The Plan denied your request. The Plan says dental services are not covered when you receive them froman out of network provider. The Plan also says that the provider in this case is not participating with the 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, dental services are not covered when you receive them from an out of network provider.Therefore, we decided that the Plan does nothave to pay forthe crown lengthening (D4249) provided on September 25, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forPhysician services provided April 30, 2019 by "the provider".You asked the Plan to pay forthe physician services. You say that the services were medically necessary and correctly billed.The Plan denied your request. The Plan says payment for the physician service at issue-a pre-operative visit-has been bundled with payment for the primary surgical procedure.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, we have confirmed that code 99233 has a bundled relationship with the surgical procedure that has already been paid and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forPhysician services provided April 30, 2019 by "the provider".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient mental health services to be provided by out-of-network provider.You asked the Plan to pre-approvethe out-of-network services. You say that the enrollee was court committed, and needs further psychiatric care.The Plan denied your request. The Plan says the services requested are available within the plan 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 pre-approve 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 servicesat issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services.Therefore, we decided that the Plan does not have to pre-approvethe inpatient mental health services to be provided by out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee refused transportation to the hospital, however they were assessed on scene. You say that the plan should cover the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the servicesprovided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on May 29, 2019.You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 did not pre-approve the servicesat 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 anesthesiaservices provided on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordialysis services provided from July 1, 2019 through August 29, 2019.You asked the Plan to waive the coinsurance fordialysis services. You say that you should not be liable for more because the provider billed different. You say that the liability should be lowered.The Plan denied your request. The Plan says the coinsurance 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 Plan clearly says that you must pay 20% coinsurance per treatment.You have been asked to pay a total of $112.04 for dialysis services. Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityJuly 9, 2019 toJuly 30, 2019Dialysis$280.0820%$56.02August 1, 2019 to August 29, 2019Dialysis$280.0820%$56.02TOTAL:$112.04
Dialysis servicesfall within the "Services to treat kidney disease" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fordialysis services provided from July 1, 2019 through August 29, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran Emergency Room visit on August 20, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the services were provided on an outpatient observation basis and the proper copay was assessed.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 a $120 copayment for Emergency Care. The enrollee has been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the Emergency 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 foran Emergency Room visit on August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammography (77066) provided on August 21, 2019.You asked the Plan to waive the copayment forthe diagnostic mammography. You say that you feel you should not have to pay this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received a diagnostic mammography on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.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 Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a preventive mammogram screening and were not charged a copayment. The file also shows you received a diagnostic mammography on the same date of service. You have been asked to pay a $35 copayment for the diagnostic mammography. The diagnostic mammography falls within the Outpatient diagnostic tests 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 diagnostic mammography (77066) provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit services provided on May 6, 2019.You asked the Plan to waive the copayment forthe office visit services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received physician services beyond the scope of an annual physical onthe date of service at issue in this case. The plan states the correct copayment has applied per your contract with the plan.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 $10 copayment for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows during your annual physical exam there was discussion regarding shoulder pain, x-rays were ordered, and there was a physical therapy follow-up. These services addressed a medical condition during the same visit as your annual physical exam. You have been asked to pay a $10 copayment for these additional office visit services. These office visit services fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe office visit services provided on May 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Chest X-ray (71045) provided June 27, 2019 by "the provider".You asked the Plan to pay forthe X-ray. You say that the X-ray was medically necessary.The Plan denied your request. The Plan says the record does not show medical necessity.The Plan must follow Medicare rules. Medicare rulessay that a chest x-ray as part of a pre-operative examination, where there is an absence of signs or symptoms indicating a need for the test, is considered not medically necessary. We looked at the file and Medicare rules. The limited records provided do not describe any signs or symptoms. Pre-operative Chest X-rays without any signs or symptoms are considered non-covered. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met.Therefore, we decided that the Plan does not have to pay fora Chest X-ray (71045) provided June 27, 2019 by "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings -4 x-rays (code D0274) provided on September 5, 2019.You asked the Plan to pay forthe bitewings. You say that you do not understand why you are being charged for the x-rays.The Plan denied your request. The Plan says this service has a limit on how often it can be paid in 12 months. The Plan also says that this limit had already 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, bitewings are limited to once every 12 months. The record shows that you received bitewings on February 12, 2019 and your bitewings benefit was then exhaustedTherefore, we decided that the Plan does not have to pay forthe bitewings -4 x-rays (code D0274) provided on September 5, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approveProlia. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not had a trial of one oral bisphosphonate and zoledronic acid as required by step therapy rules.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 Prolia. Our reviewer says that the enrollee has not met criteria for Prolia. Our physician reviewer found the Plan requires a trial of one oral bisphosphonate and zoledronic acid first before they will approve the requested drug, Prolia. The provided medical records do not indicate that the patient has tried and failed the required drugs, or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (J0897).