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

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on September 18, 2020.
You asked the Plan to pay for the incisional biopsy. You say that you have a history of cancer and felt this service was necessary. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 incisional biopsy of oral tissue (D7286) provided on September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on October 27, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21. We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue. The claim was not billed with the required POS code 21. 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 computed tomography (CT) scan of the head/brain rendered on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) on November 02, 2020.
You asked the Plan to waive the copayment for the office visit. You say that should not be held liable for the cost share on this claim because you had already met your out of pocket maximum for 2020. The Plan denied your request. The Plan says that you met your out of pocket maximum in previous months, but there was an adjustment to a claim that caused the out of pocket maximum to no longer be met.
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 Physician/Practitioner services, including doctor's office visits. You have been asked to pay a $50 copayment for an office visit. This service falls within the Physician/Practitioner services, including doctor's office visits benefit category. The record shows that you did not meet the maximum out of pocket limit of $6,700 before the date of service at issue. 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 the office visit (99203) on November 02, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 4, 2020.
You asked the Plan to pay for the knee orthosis (L1833RT) and suspension sleeve (L2397RT). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says they do not have a claim for the ordering physician.
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 knee orthosis (L1833RT) and suspension sleeve (L2397RT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the enrollee's chief complaint was chronic knee pain. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity.
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 knee orthosis (L1833RT) and suspension sleeve (L2397RT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with the 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 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 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 medical services provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on August 15, 2020.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on August 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy.

You asked the Plan to pay for the endodontic therapy. You say that you do not understand why this service was denied coverage. The Plan denied your request. The Plan says this service is not covered under your dental 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 endodontic therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test provided on November 6, 2020.
You asked the Plan to pay for the COVID-19 test. You say that you would like reconsideration because this test was required for you to return to New York State. The Plan denied your request. The Plan says testing that is ordered or performed solely for pandemic control such as testing of asymptomatic individuals to assess health status as required by an employer, school, camp, travel authority/advisory, common carrier, government/public health agency, or research/epidemiologic study and not based on a determination by an attending provider that the test is medically appropriate for the diagnosis and treatment of an individual is not covered.
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 test have not been met. Specifically, the record indicates that this testing was performed without a relationship to treatment or diagnosis for a specific illness and was required by a third party. Therefore, we decided that the Plan does not have to pay for the COVID-19 test provided on November 6, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a panniculectomy procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that a panniculectomy is not medically necessary for the repair of a hernia.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 requested services. Our physician reviewer found that the enrollee has a large ventral hernia. It is noted that the enrollee has had recurrent hernias, and that her panniculus has contributed to this due to physical drag on the abdominal wall. The physical exam demonstrated a significant ventral hernia at the level of the umbilicus and below, with a large amount of excess skin below the site. The documentation supports that a panniculectomy combined with hernia repair is medically reasonable and necessary for the enrollee in this case. The hernia recurrence rate is low when panniculectomy is combined with ventral hernia repair, and the safety of the combined procedure supports its current implementation. 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 been met. Therefore, we decided that the Plan has to pre-approve a panniculectomy procedure.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
Medicare eligible.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient residential treatment for alcohol and /or drug rehabilitation provided on July 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient residential treatment for alcohol and /or drug rehabilitation. You say that you did not have time to receive prior authorization. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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 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 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 inpatient residential treatment for alcohol and /or drug rehabilitation provided on July 29, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 11, 2020.
You asked the Plan to pay for the dental service. You say that you are covered for a cleaning. You say that this is your normal cleaning. You also say that this is just a more thorough cleaning. The Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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 periodontal maintenance (D4910) provided on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on September 10, 2020 and September 17, 2020.
You asked the Plan to waive the copayment for outpatient hospital services. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was 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 a $250 surgery copayment for Outpatient hospital services. You have been asked to pay a $250 surgery copayment for outpatient hospital services. This service 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 waive the copayment for outpatient hospital services provided on September 10, 2020 and September 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services.

You asked the Plan to pay for the services provided. You say that no pre-certification was required within 48 hours. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 

We looked at the file, and Medicare rules. In this case, there were insufficient records to show that the services were urgent or emergent. The services were not pre-approved by the Plan. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that you went to this provider as a new patient. You say that this visit was not a restorative visit. You also say that this service should be changed to "evaluation". The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service.

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 limited oral evaluation (D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on January 28, 2020.

You asked the Plan to pay for the hearing aids. You say that you do not know how to look up network providers. The Plan denied your request. The Plan says the benefit is not covered when received from an out-of-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. 

We looked at the file, and the Plan's rules. The provider in this case is not a network provider with the Plan. Your plan only covers hearing aids when obtained from an in-network provider. 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 provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 20, 2020, to October 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you were never notified that this provider was no longer in-network. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 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 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 physician services provided on October 20, 2020, to October 28, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Actemra (tocilizumab), 80 mg/ml vial, intravenously.

You asked the Plan to pre-approve tocilizumab. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that tocilizumab is only supported for your diagnosis when administered intravenously. The Plan also says that the criteria for coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 tocilizumab. Our reviewer says that tocilizumab given intravenously is medically necessary. Our physician reviewer found tocilizumab is not FDA-approved for the enrollee's diagnosis. The reviewer found that there are several studies that demonstrate the efficacy of tocilizumab for the treatment of polymyalgia rheumatica in addition to an accompanying reduction, or even tapering of corticosteroids. The reviewer found that it is appropriate in this case to provide this drug via IV injection. The reviewer also found that it is reasonable and necessary in this case for IV injection. Therefore the reviewer found that the documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tocilizumab have been met. Therefore, we decided that the Plan has to pre-approve Actemra (tocilizumab), 80 mg/ml vial, intravenously.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 4, 2020.

You asked the Plan to waive the copayment for the laboratory work. You say that you should not be responsible for the copayment because there were no results and they told you they could not use the blood. 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 $10 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services. 

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows that laboratory services were performed and results were sent to your doctor.

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 the laboratory work provided on September 4, 2020.