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

We decided that the Plan does not have to waive the cost-sharing for Medicare Part B drugs, arterial imaging studies, an ultrasound examination, imaging contrast materials, and artery surgery provided.

You asked the Plan to waive the cost-sharing for Part B drugs, arterial imaging studies, ultrasound exam, imaging supplies, and specialist surgical service. You say that this procedure failed, and you paid a $25 copayment at this visit.The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.

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 Part B drugs, $135 copayment for each diagnostic radiology service, 20% coinsurance for imaging supplies, and $25 copayment for specialist service.For some of the services you have been asked to pay the allowed amount of the service if it is less than the applicable cost-sharing amount.A summary of your cost-sharing amounts is shown on the next page:our total cost-sharing responsibility is therefore $590.99.

You have been asked to pay 20% coinsurance for Part B drugs, $135 copayment for each diagnostic radiology service, 20% coinsurance for imaging supplies, and $25 copayment for specialist service. Part B drugs, arterial imaging studies, ultrasound exam, imaging supplies, and specialist surgical service fall within the "Medicare Part B Prescription Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies", and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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-sharing for Medicare Part B drugs, arterial imaging studies, an ultrasound examination, imaging contrast materials, and artery surgery provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional six (6)PT visits.


You asked the Plan to pre-approve an additional six (6) PT visits. You say that the enrollee is still having significant issues with activities of daily living. The Plan denied your request. 

The Plan says the enrollee does not meet the Medicare criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 an additional six (6) PT visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and it does not appear that the enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The documentation does not reveal measurable objective functional improvement from prior therapy. The enrollee has had instruction in a home exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional six (6) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional six (6) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided on August 7, 2020.You asked the Plan to pay forthe dental service. You say that you were aware that the provider in this case was out of network. You say that you were aware that only 50% would be reimbursed instead of the full amount. You say that you did not make the call on whether you would get a regular cleaning versus the periodontal maintenance. You also say that your Evidence of Coverage does not specifically say which type of cleaning would be covered; it only says prophylaxis. You also say that the service should at least be partially covered.The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that the Evidence of Coverage specifically lists a prophylaxis cleaning as a covered service. The Plan also says that a periodontal cleaning is to treat active dental disease while prophylactic cleaning is preventative in nature.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 forthe periodontal maintenance (D4910) provided on August 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay formedical services provided to the enrollee on November 6, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says due to the enrollee'shospice election at the time of service, this claim should be submitted to Original Medicare. The Plan says that the recordsshow the enrollee was enrolled in hospice from November 6, 2017 to October 26, 2019 and then again from November 6, 2019 to October 30, 2020.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay formedical services provided to the enrollee on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Botox injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that the injections have been helping the enrollee treat the migraines. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found a review of the records does not support a decrease in the frequency or intensity of the headaches with the requested treatment. Without the support of the documentation 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Botox injections for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, for example: a skilled nursing facility, home with home health, and home physical therapy.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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a hip fracture and wrist fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, andan intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 76536) provided on August 20, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says only one unit of this code is 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.We find that an additional unit of CPT code 76536 is not supported in the medical record. Specifically, the records only support one unit of CPT 76536, which the Plan has paid. Based on thisinformation, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 76536) provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (80307 and G0483) provided on May 22, 2020.
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the submitted medical documentation indicates that the
specimen was obtained in an office setting.
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used
to reflect the actual setting where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug test have not been met. Specifically, the record indicates that the specimen was collected
in an office setting and this claim was billed with the laboratory place of service code. Therefore, we decided
that the Plan does not have to pay for the drug test (80307 and G0483) provided on May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSuperion interspinous spacer.You asked the Plan to pre-approveSuperion interspinous spacer. 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 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 Superion interspinous spacer. 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 back pain. The requested spacer remains experimental. More research is needed to show safety and 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 Superion interspinous spacer have not been met.Therefore, we decided that the Plan does not have to pre-approveSuperion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis billed for date of service August 25, 2020.
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the documentation submitted does not support the date of service billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that, for items furnished to the enrollee by delivery, the date of service billed should be the date of delivery or in some cases the shipping date. We looked at the file and Medicare rules. The documentation does not support that the billed date of service August 25, 2020 was either the date of delivery or the date of shipping for this item. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis billed for date of service August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99238) provided on January 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 99238 is part of an edit pair with procedure code 99239. Procedure code 99239 is a column one code, and procedure code 99238 is a column two code. Procedure code 99239 has been paid for this date of service, which means that procedure code 99238 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (CPT 99238) provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the complete series of x-rays (D0210), and the panoramic x-ray (D0230) provided on May 18, 2020.You asked the Plan to pay forthe dental services. You say that you were in great pain. You say that you had to see a new dentist which required x-rays to diagnose the problem. You say that you had no knowledge that the frequency limit had been exceeded. You also say that the services you received were an emergency.The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says 1 complete series of x-rays is covered every 3 plan years. The Plan says 1 panoramic x-ray is covered every 3 plan years. The Plan also says that the frequency limits for these services have 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, the frequency limits of 1 comprehensive oral evaluations, complete series of x-rays, and panoramic x-rayevery 3 years have been exceeded. The record shows that the Plan paid for the comprehensive oral evaluation that you received on May 24, 2018, the complete series of x-rays that you received on July 11, 2018, and the panoramic x-ray that you received on July 11, 2018.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the complete series of x-rays (D0210), and the panoramic x-ray (D0230) provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services you received on July 30, 2020.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says out-of-network services are not covered.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 services are not among those covered under this benefit when provided by an out-of-network provider. You must pay 100% of the cost of dental services provided by an out-of-network provider.Therefore, we decided that the Plan does not have to pay forthe dental services you received on July 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health hospital stay
provided by a participating provider on May 15, 2020, to May 20, 2020.
You asked the Plan to waive the copayment for an inpatient mental health hospital stay. You say that you do
not feel this stay was necessary. The Plan denied your request. The Plan says the correct copayment has been
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 $230
copayment per day for days 1-7. There is no charge for additional days for inpatient mental health care.
You have been asked to pay a $230 copayment per day for days 1-5 for an inpatient mental health hospital stay.
The total amount you are being asked to pay is $1,150 ($230 x 5 days = $1,150). Since an inpatient mental
health hospital stay did occur, the correct copayment has been applied. An inpatient mental health hospital stay
falls within the inpatient mental health care 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 an inpatient mental health hospital stay provided by a participating provider on May 15, 2020, to May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a suction pump (model electric use external urine device).
You asked the Plan to pre-approve a suction pump. 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 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 a suction pump. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found you have urge incontinence. Anticholinrgics, myrbetriq and Interstim have not been effective.
Interstim was placed 2014. You are currently taking Myrbetriq. You wear 2-3 pads per day. The documentation
does not support that you have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for
coverage of Purewick (electric suction external urine collection device). Therefore, you do not meet criteria for
the requested services/items.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a suction pump have not been met. Therefore, we decided that the Plan does not
have to pre-approve a suction pump (model electric use external urine device).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical cancer screening rendered on April 10, 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 the services exceed the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that a cervical cancer screening is covered once every 24 months. We looked at the file and Medicare rules. The file shows that you had a cervical cancer screening on April 10, 2019. You previously received these services on July 9, 2018 and the Plan paid for this exam. The services on April 10, 2019 were performed less than 24 months after your previously covered exam. Therefore, we decided that the Plan does not have to pay for the cervical cancer screening rendered on April 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 21,
2020, to August 19, 2020.
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the enrollee used over the 100 days of SNF level of care
during the benefit period and no further days can be paid.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone sixty days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from December 15,
2019, to July 20, 2020. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 21, 2020, to
August 19, 2020.