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

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the service is considered experimental and investigational.
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 requested services. Our physician reviewer found that the requested device is considered experimental. More research is needed to show its safety and efficacy. Therefore, the requested services are not considered medically reasonable or necessary. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on August 5, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you did not receive an injection on that date of service. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug provided on August 5, 2020. The allowed amount is $12.19 and 20% of that is $2.44. You have been asked to pay the total coinsurance amount of $2.44 for a Medicare Part B drug. A Medicare Part B drug 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 waive the coinsurance for a Medicare Part B drug provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit (99214, 99215) provided on August 6, 2020 to September 14, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe office visits. You say that this procedure was medically necessary. Please review and reprocess the claim for payment.The Plandenied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent 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 outpatient office visit (99214, 99215) provided on August 6, 2020 to September 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided.

You asked the Plan to waive the deductible for the office visit. You say that the cost is excessive for a visit. You say that you are appealing the charge.The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your combined deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. 

Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received.Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran echocardiography and does not have to waive the coinsurance for myocardial perfusion imaging provided on July 14, 2020.You asked the Plan to waive the coinsurance foran echocardiography and to waive the coinsurance for myocardial perfusion imaging. You say that you had the tests done outpatient instead of at the emergency room to avoid COVID-19.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 20% coinsurance for diagnostic procedure and tests provided at outpatient hospital facilities and a $250 copayment for advanced imaging services provided at outpatient hospital facilities.You received an echocardiography on July 14, 2020. The allowed amount is $499.37 and 20% of that is $99.87. You received myocardial perfusion imaging on July 14, 2020. Therefore, you are responsible to pay the $250 copayment. The total amount you owe is: $349.87. You have been asked to pay the total amount of $349.87 for an echocardiography and myocardial perfusion imaging. An echocardiography and myocardial perfusion imaging fall 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 coinsurance foran echocardiography and does not have to waive the coinsurance for myocardial perfusion imaging provided on July 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation and does not have to waive the coinsurance for Medicare Part B drugs provided on March 9, 2020.
You asked the Plan to waive the copayment for chemodenervation and to waive the coinsurance for Medicare Part B drugs. You say that you have never had to pay for the injections in the past and disagree with the charges. 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 $50 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received chemodenervation on March 9, 2020. Therefore, you are responsible to pay the $50 copayment. You received Medicare Part B drugs on March 9, 2020. The total allowed amount is $1,224 and 20% of that is $244.80. The total amount you owe is: $50 + $244.80 = $294.80. You have been asked to pay the total amount of $294.80 for chemodenervation and Medicare Part B drugs. Chemodenervation falls within the physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall 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 waive the copayment for chemodenervation and does not have to waive the coinsurance for Medicare Part B drugs provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe upper extremity fracture brace provided on August 11, 2020.You asked the Plan to waive the coinsurance forthe upper extremity fracture brace. You say that you already paid a $35 copayment for every visit. You say that the provider doesn't deserve anymore.The Plan denied your request. ThePlan 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% of the plan-allowed amount for Medicare-covered prosthetic devices and medical supplies from an in-network provider. You have been asked to pay $72.82, which is 20% of the allowed amount for the upper extremity fracture brace. The allowed amount is $364.10 (20% x $364.10 = $72.82). The upper extremity fracture brace falls within the "Prosthetic devices and related 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 coinsurance forthe upper extremity fracture brace provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea full mouth debridement (D4355), pontics(D6750) for teeth # 18, 20, 29 and 32, and retainer crowns (D6240) for teeth # 19, 30, and 31.

You asked the Plan to pre-approve the dental services. You say that the enrollee is in pain. You say that the enrollee needs the bridge.The Plan denied your request. The Plan says the requested bridge is not medically necessary at this time. The Plan says that the submitted narrative fails to indicate or support any specific physical or psychological condition(s) that preclude the use of a removable prosthesis. The Plan says that full mouth debridement is not covered within 12 months of a cleaning or oral or periodontal evaluation. The Plan also says that the enrollee received an oral evaluation.

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 services 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 services. Our reviewer says that the bridge is not medically necessary. Our physician reviewer found the requested treatment is a reasonable treatment modality. The reviewer found that the plan limitations do not allow for fixed bridges except in very limited circumstances. The reviewer found that the provided documentation does not show any indication that the limited circumstances for a bridge to be covered are applicable in this case. Therefore, the reviewer found that the requested bridge is not medically necessary.


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 bridge has not been met. Additionally, though the Plan offers a dental benefit in excess of Medicare coverageand full mouth debridement is a covered service, it is not covered when you receive this service within 12 months of a cleaning, or oral or periodontal evaluation. The record shows that you received an ora.

Therefore, we decided that the Plan does not have to pre-approvea full mouth debridement (D4355), pontics (D6750) for teeth # 18, 20, 29 and 32, and retainer crowns (D6240) for teeth # 19, 30,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation.You asked the Plan to pre-approveradiofrequency ablation. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that arenot 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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral Sacro-ilitis. The enrollee is taking Tramadol, Flexeril, Naproxen, and Percocet. The enrollee had radiofrequency ablation of the lateral sacral branches in 2017 with good effect. This procedure is considered experimental/ investigational because of the wide variation in efficacy. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from May 17, 2020, to May 26, 2020.
You asked the Plan to pay for the SNF stay. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the SNF stay was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service or skilled therapy needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF stay have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from May 17, 2020, to May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided by an out of network (OON) provider.

You asked the Plan to pay for the lab services. You say that when the enrollee switched insurance at the beginning of the year, you did not realize that his family doctor was no longer a plan provider.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found noexception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the lab services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the lab services. You say that you have been using this provider, but you just learned they don't accept your insurance. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could 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 lab services provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the ultrasound services coded 76775 provided on July 8, 2020.
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable.
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. Review of the file shows that the Plan cites Medicare Claims Processing Manual
Chapter 19 as reasoning why this claim was denied. The Plan also states that per this citation, the claim was not billed in accordance with CMS guidelines. The documentation shows that the charge for the claim exceeds fee schedule/maximum allowable fee. However, no other documentation was provided to support their denial. The documentation does not support why the claim was not paid at the allowable amount. No reasoning on what in Medicare Claims Processing Manual Chapter 19 makes the claim billed inappropriately. The documentation is missing required information to substantiate a denial of the claim. Therefore, we decided that the Plan has to pay for the ultrasound services coded 76775 provided on July 8, 2020.
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 pre-approve the Barostim Neo System (0266T).
You asked the Plan to pre-approve (0266T) implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed). You say that this system is medically necessary for functional improvement and symptom management. The Plan denied your request. The Plan says there is not enough clinical evidence in peer-reviewed medical journals that shows that this service improves long term health outcomes.
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 (0266T) implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance one small trial using the System to activate carotid baroreceptors reported improved quality of life and exercise capacity. However, in this trial there is a potential significant selection bias as there was no sham control arm. There are no trials that demonstrate reduced hospital readmission or improved survival. Therefore, the efficacy of baroreceptor activation in heart failure is still uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, in my opinion, since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of (0266T) implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation or replacement of carotid sinus baroreflex activation device (0266T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation (D0120) and bite-wing - four radiographic images (X-Ray) (D0274) provided on September 20, 2020.
You asked the Plan to pay for periodic oral evaluation and bite-wing X-Rays. You say that you should not be billed for this as you have never been billed for these services before. The Plan denied your request. The Plan says there is a $15 copayment for each routine oral exam and a $15 copayment for bitewing x-rays.
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. This benefit includes bitewing x-rays with a $15 copayment and routine oral exams with a $15 copayment. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are subject to a cost share. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120) and bite-wing - four radiographic images (X-Ray) (D0274) provided on September 20, 2020.