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

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on October 31, 2019.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that you had to get clearance from your dentist for your upcoming total knee replacement surgery, per the surgeon's request.The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, exams are limited to two procedures per plan year. The records show that you received problem focused limited oral evaluations on January 15, 2019 and September 16, 2019 and your exams benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS device.You asked the Plan to pre-approvethe requested device. You say that management by conservative means only is ineffective.The Plan denied your request. The Plan says there is no definitive evidence that the monitor has been established as a standard of care to improve cardiac 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 the requested device. Our physician reviewer found that therapy change based on data obtained from a CardioMEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is 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, since the device is 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 the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approvea CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on February 10, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the
provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
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. The medical records do not mention or support medical necessity for
the orthoses. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral
orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral
orthosis provided on February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided to the enrollee on December 26, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. Welooked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted did not indicate the provider discussed the need for the billed supply code; thereforethe billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided to the enrollee on December 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation and inpatient care
provided from January 3, 2020 to January 7, 2020.
You asked the Plan to waive the copayment for ambulance transportation and inpatient care. You say that you
should not have been discharged and should not have to pay for these services. The Plan denied your request.
The Plan says these services processed 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 a $250
copayment for each one-way Medicare-covered ambulance transport and a $325 copayment per day for days 1-
5 for each Medicare-covered hospital admission/stay.
You have been asked to pay $250 for ambulance transportation and $1,300 for four days of inpatient care (4 x
$325 = $1,300). 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 ambulance transportation and
inpatient care provided from January 3, 2020 to January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose injection provided on November 27, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you were not told about these charges. The Plan denied your request. The Plan says that this processed 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 a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The 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 waive the coinsurance for the ferric carboxymaltose injection provided on November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Escitalopram Tab 10mg.You asked the Plan to pre-approve Escitalopram Tab 10mg. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveEscitalopram Tab 10mg.Benefits for Escitalopram Tab 10mgmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on December 24, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was provided by an out of network providerat a non-participating facility, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on December 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance transport provided on January 20, 2020.
You asked the Plan to waive the deductible for the ambulance transport. The Plan denied your request. The Plan says that until you have paid the deductible amount, you must pay the full cost for most of the covered services.
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 there is a $750 deductible for covered services. The item or service you asked the Plan to waive the deductible for falls within the covered services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for covered services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on January 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance transport provided on January 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided from January 21, 2020 to January 25, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that youshould 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 $225 copayment for each in-network Medicare-covered advanced imaging service (not including x-rays). You have been asked to pay a $225 copaymentfor the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you received two CT scans during your emergency room stay.This means that you have been asked topay 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 CT scan providedfrom January 21, 2020 to January 25, 2020. Your complaint about the hospital's negligence is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal manipulation (98940) and low-level laser treatment
(S8948) provided by a chiropractor on December 5, 2018 to December 27, 2018.
You asked the Plan to pay for spinal manipulation and low-level laser treatment. You say that these services are
medically necessary. The Plan denied your request. The Plan says these services processed 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 a $20
copayment for each Medicare-covered visit for the manual manipulation of the spine to correct subluxation.
The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to
correct a subluxation.
You have been asked to pay a $60 copayment for three spinal manipulation services (3 x $20 = $60). 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. Low-level laser treatment
is not a covered chiropractic service. Therefore, we decided that the Plan does not have to pay for spinal
manipulation (98940) and low-level laser treatment (S8948) provided by a chiropractor on December 5, 2018
to December 27, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care from December 2, 2019 through December 3, 2019 provided by an out-of-network provider.You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services due to the quality of care you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan also stays they created a separate case to address your quality of care concerns.The rules say a plan must disclose to its enrollees in clear,accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from December 2, 2019 through December 3, 2019 provided by an out-of-network provider. You are asked to pay 40% coinsurance for the inpatient hospital care. 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 inpatient hospital care from December 2, 2019 through December 3, 2019 provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the infusions and the administrations provided from November 5, 2019 to November 27, 2019.
You asked the Plan to waive the cost share for the infusions and the administrations. You say that it was your understanding that the iron infusions were covered in full. You say you asked at each infusion if you owed anything and were told there was no 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 20% coinsurance for each in-network Medicare-covered Part B drug and a $50 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay $164.55 which is 20% of the allowed amount for the infusions on each date of service. The allowed amount is $822.75. ($822.75 x 20% = $164.55) ($164.55 x 3 dates of service = $493.65).
You have also been asked to pay a $50 copayment for the administrations on each date of service. ($50 x 3 dates of service = $150).
The infusions fall within the "Medicare Part B Prescription Drugs" benefit category. The administrations fall 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 cost share for the infusions and the administrations provided from November 5, 2019 to November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Celecoxib capsules.
You asked the Plan to pre-approve the Celecoxib. You say that you would like reconsideration because you have been taking this drug and do not feel comfortable taking anything else. The Plan denied your request. The Plan says this medication does not fall under Medicare Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Celecoxib capsules.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional home health physical and occupational therapy visits for the enrollee.You asked the Plan to pre-approve the services. You say that there is no documentation of a progressive neuromuscular disease, progressive dementia, or cystic fibrosis.The Plan denied your request. The Plan says this is medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found it is not clear the duration of her dependent functional status, nevertheless she is total care. The records do not show that skilled nursing services are required besides routine care already provided by the attendant. These services are not to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The services do not meet the definition of home health aide criteria. The home health aide services requested for PT and OT are not reasonable and medically necessary for the treatment of the enrollee's illness described above by the skilled professional staff.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 pre-approve four additional home health physical and occupational therapy visits for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octagam (J1568).You asked the Plan to pre-approve Octagam. You say that the requested medication is necessary.The Plan deniedyour request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that the use of intravenous immune globulin (IVIG) is covered when specific criteria is met.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 Octagam. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee has Stage IV Bcell lymphoma and secondary hypogammaglobulinemia. Review of the compendia does not support Octagam for this diagnosis. Medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Octagam have not been met.Therefore, we decided that the Plan does not have to pre-approveOctagam (J1568).
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 you had broken your leg and were unable to move. You say that your wife called for an ambulance, and the responders told you that they could only take you to the hospital and not to a doctor's office. You stated that they helped you off of your couch to the car and your wife drove you to your doctor's office. You say that the ambulance responders would have taken you to the hospital, but you did not want to go to the hospital.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 February 6, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forcystourethroscopy (52240) provided on December 10, 2019.You asked the Plan to pay forthe cystourethroscopy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 52240 is cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s).We asked our coder 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 cystourethroscopy. Our reviewer says that CPT code 52240 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation to validate that a Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s) was performed. There is not documentation corroborating a tumor larger than 5cm, therefore this service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy have not been met.Therefore, we decided that the Plan does not have to pay forcystourethroscopy (52240) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on November 18, 2019.
You asked the Plan to pay for the services. You say that the provider told you they were in-network. The Plan
denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to you by an out-of-network provider on
November 18, 2019.