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

We decided that the Plan does not have to pay for the replacement of a broken tooth provided on December 31, 2019.
You asked the Plan to pay for the replacement of a broken tooth. You say that when the technician took your denture and teeth you gave them, they never told you that they were replacing the teeth. The Plan denied your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has been exceeded.
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, denture adjustments are limited to one procedure per calendar year. The record shows that you received two replacements of broken teeth on December 31, 2019, one of which was covered by the Plan, and your denture adjustments benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the replacement of a broken tooth provided on December 31, 2019.
Your complaint about the provider's negligence and bad business 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on September 13, 2019.
You asked the Plan to pay for the hearing aids. You say that you are requesting reconsideration for
reimbursement for the purchase of the hearing aid that you paid for out of pocket. The Plan denied your
request. The Plan says enrollee's must receive hearing services form an in-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when the services are received from a participating provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids purchased on September 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance for the stress test you received on February 6, 2020.You asked the Plan to waivethe stress test. You say that you cannot afford to pay this.The Plan denied your request. The Plan says the claim 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 outpatient hospital services. Review of the file shows that you were provided a stress test on February 6, 2020. The stress test was allowed at $1,439.83. You have been asked to pay a 20% coinsurance for the stress test, totaling $287.97 (1,439.83 x 20% = $287.97). The stress test falls within the outpatient hospital 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 waivethe coinsurance for the stress test you received on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 5, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says the provider is not a network provider with your plan.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 hasnetwork 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 nothave to pay forthe medical services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 63685 and 63650 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 63685 is insertion or replacement of spinal
neurostimulator pulse generator or receiver, direct or inductive coupling. The definition of code 63650 is
percutaneous implantation of neurostimulator electrode array, epidural.
We find that CPT codes 63685 and 63650 are not supported in the medical record. Specifically, there is no
documentation of an insertion or replacement of a spinal neurostimulator pulse generator or receiver to support
code 63685 or percutaneous implantation of a neurostimulator electrode array to support code 63650. Based on
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore,
we decided that the Plan does not have to pay for the surgical services rendered on August 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 21,
2019 to December 15, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
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 skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 21, 2019 to December 15,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on December 18, 2019. You asked the Plan to pay for the prophylaxis. You say that you are covered under Medicare health insurance. The Plan denied your request. The Plan says this service is not covered under 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 23, 2020 by an out of network (OON) provider.You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when received by an OON provider.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 office visit provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOptune Lua plus Transducers (E0766).You asked the Plan to pre-approveOptune Lua plus Transducers. You say that the item is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) 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 determineif the Plan was correct in denying the request to pre-approve Optune Lua plus Transducers. Our reviewer says that the item is not medically necessary. Our physician reviewer found mesothelioma is not a covered diagnosis for the requested treatment. The requested treatment is not medically reasonable and 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 Optune Lua plus Transducershave not been met.Therefore, we decided that the Plan does not have to pre-approveOptune Lua plus Transducers (E0766).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveinpatient mental health care, for the enrollee.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that the stay is medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatientpsychiatric hospital services. Our physician reviewer found It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care due to dangerousness of self. The health plan's denial of inpatient psychiatric services appears inappropriate. This enrollee did appear to require inpatient mental health treatment as he was voicing suicidal thoughts with a specific plan. It did appear that active treatment was taking place. It did appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself but not others, without agitation or aggression without perceptual disturbance including auditory or visual hallucinations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met.Therefore, we decided that the Plan has to pre-approve inpatient mental health care, for the enrollee.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 a liver biopsy.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the gastric bypass is approved but the liver biopsy is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has morbid obesity and a body mass index (BMI) of 40 kg/m2. There is no evidence of fatty liver, elevated liver enzymes, or symptomatic liver disease. There is no medical standard for routine liver biopsy during bariatric procedures. The enrollee has no known liver disease that warrants biopsy; therefore, the requested services are not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a liver biopsy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for keratoplasty provided on December 4, 2019.You asked the Plan to waive the coinsurance for keratoplasty. You say that you disagree with the charges because you were not aware that you would owe anything since you did not owe anything in the past.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 40% coinsurance for out-of-network outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received keratoplasty from an out-of-network provider on December 4, 2019. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is $3,343.21 and 40% of that is $1,337.28. You have been asked to pay the coinsurance amount of $1,337.28 for keratoplasty. Keratoplasty 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 coinsurance for keratoplasty provided on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHymovis.You asked the Plan to pre-approveHymovis. 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 follows Medicare rules. Medicare rules say that Hymovis is only covered for certain indications.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 Hymovis. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not include a detailed examination of the knee, radiographic studies of the knee documenting nee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts, or a details of conservative treatments trialed. Additionally, documentation does not support the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy,as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Guidelines as outlined by the plan are not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approveHymovis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit provided on November 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient clinic visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-directed.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 clinic visit provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tint, photochromatic, per lens (V2744) lens upgrade
purchased December 6, 2019.
You asked the Plan to pay for the lens upgrade. You say that due to your prescribed daily doses of Plaquenil,
you are highly sensitive to excessive sunlight. This prescription is essential for your treatment and yet you want
to maintain good eye health as well. The Plan denied your request. The Plan says the requested service is not a
covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan allows coverage for eyewear after cataract surgery however covered eyeglasses after
cataract surgery only includes standard frames and lenses as defined by Medicare; any upgrades are not
covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating.
We looked at the file and the Plan's rules. upgrades on lenses are not covered Based on this information, we
decided that the Plan's rules for coverage of the lens upgrade have not been met. Therefore, we decided that the
Plan does not have to pay for tint, photochromatic, per lens (V2744) lens upgrade purchased December 6,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from November 19, 2019, to November 21, 2019.You asked the Plan to pay forthe acute inpatient hospital care. The Plan denied your request. The Plan says the enrollee did not meet inpatient criteria.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented with complaints of chest discomfort for several days on November 19, 2019. She was admitted for evaluation for possible acute coronary syndrome. By November 20, 2019, she had completed laboratory, radiographic and EKG evaluation and had consultation with cardiology. Symptoms had improved and were determined not to be cardiac in nature. She remained in the hospital for an additional day while awaiting gastroenterology evaluation. An outpatient workup was recommended for possible GI source of symptoms and she was discharged. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Inpatient admission was not medically 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from November 19, 2019, to November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration services coded 96413, 96411, 96417, and the injection services coded 96375 provided on November 6, 2019.
You asked the Plan to pay for the chemotherapy administration services and the injection services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 96413, 96411, 96417, and 96375 are not supported in the medical record. Specifically, the submitted medical records do not include start and stop times indicating chemotherapy administration, intravenous infusion technique; up to 1 hour was performed. Therefore, code 96413 cannot be verified. Add-on codes 96411, 96417, and 96375 are not supported due to the primary procedure code of 96413 being denied. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration services and the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration services coded 96413, 96411, 96417, and the injection services coded 96375 provided on November 6, 2019.