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

We decided that the Plan does not have to waive the copayments for the physical therapy visits and the
emergency room visit provided from June 5, 2020, to August 3, 2020.
You asked the Plan to waive the copayments for the physical therapy visits and the emergency room visit. You
say that you should not be responsible for the copayments. 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 $40
copayment for Medicare-covered in-network outpatient rehabilitation services and a $90 copayment for
Medicare-covered emergency care visits.
You have been asked to pay a $40 copayment for each of the physical therapy visits. ($40 x 13 visits = $520).
You have also been asked to pay a $90 copayment for the emergency room visit. ($590 + $90 = $610). The
physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The emergency
room visit fall within the "Emergency 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 copayments for the physical therapy visits and the emergency room visit
provided from June 5, 2020, to August 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to cover the second annual depression screening provided.

You asked the Plan to cover the second annual depression screening. You say that you did not get a second depression screening at this follow up office visit.The Plan denied your request. The Plan says that the benefit for an annual depression screening is exhausted.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The medical records are in consistentand do not substantiate two depression screenings.Therefore, we decided that the Plan has to cover the second annual depression screening claim, submitted by the contract provider.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora neuromuscular stimulator unit provided on August 19, 2020.You asked the Plan to pay forneuromuscular stimulator. 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 this is not covered by Medicare.The Plan follows Medicare rules. Medicare rules state that NMES is only covered for certain conditions of muscle atrophy or spinal cord injury.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 neuromuscular stimulator. Our reviewer says that this device does not meet the Medicare criteria for coverage. Our physician reviewer found this type of device is typically used for walking in a patient with disuse atrophy where nerve supply to the muscle is intact or with a spinal cord injury (SCI). This device is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning ofa malformed body member for this enrollee. There is no objective evidence of a spinal cord injury or disuse muscle atrophy from a non-neurological cause. This item does not appear to be the standard of care for this condition and exceeds the enrollee's medical need.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular stimulator have not been met.Therefore, we decided that the Plan does not have to pay fora neuromuscular stimulator unit provided on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDalfampridine Tablet.You asked the Plan to pre-approveDalfampridine Tablet. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.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-approveDalfampridine Tablet.Benefits for Dalfampridine Tabletmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted to the acute care hospital on December 22, 2020 with a subdural hematoma. Middle meningeal artery embolization and cranial evaculation were performedon December 24, 2020. A tracheostomy and percutaneous endoscopic gastrostomy(PEG) tube have been placed. On January 22, 2021, the enrollee had a Glasgow Coma Score of 3, with no eye opening, verbal or motor response. The enrollee's pupils were noted to be pinpoint, symmetrical and bilaterally reactive. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular embolization or occlusion, inclusive of all
radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to
complete the intervention; arterial, other than hemorrhage or tumor.
You asked the Plan to pre-approve vascular embolization or occlusion, inclusive of all radiological supervision
and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention;
arterial, other than hemorrhage or tumor. 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 vascular embolization or occlusion,
inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance
necessary to complete the intervention; arterial, other than hemorrhage or tumor. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found you have benign prostatic hyperplasia (BPH) and lower urinary tract symptoms for many years.
Prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic BPH. Very limited
international studies have demonstrated possible short-term safety and efficacy. Comparative studies to other
methods are currently enrolling enrollees. The most recent AUA guidelines do not recommend this procedure
outside of a clinical trial setting. Therefore, you do 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 vascular embolization or occlusion, inclusive of all radiological supervision and
interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention;
arterial, other than hemorrhage or tumor have not been met. Therefore, we decided that the Plan does not have
to pre-approve vascular embolization or occlusion, inclusive of all radiological supervision and interpretation,
intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than
hemorrhage or tumor.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71045) provided on July 27, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says that CPT code 71045 was not billed with an
appropriate modifier to indicate it was a separate procedure from CPT code 32555.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to
NCCI edits.
We find that CPT code 71045 is supported in the record. Specifically, the record indicates that CPT codes
71045 and 32555 were rendered by different providers with separate NPIs. It is not appropriate to apply NCCI
edits to providers with different NPIs. Based on this information, we decided that Medicare rules for coverage
of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest x-ray (71045)
provided on July 27, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the deductible for the hernia surgery provided on June 25, 2020. You asked the Plan to waive the deductible for the hernia surgery. You say that you met your $1,000 deductible and that the surgery was performed in-network. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit records to support that the deductible had not been met. Therefore, the Plan has not shown that the deductible amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the deductible for the hernia surgery provided on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composites (D2335 and D2394) provided on August 11, 2020.You asked the Plan to pay forthe resin-based composites (D2335 and D2394). You say that your cost was $80 each according to the treatment plan but you later received an invoice for $530. You say that there was no mention that most of your procedures wouldn't be covered.The Plan denied your request. The Plan says the services are not covered benefits.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 resin-based composites (D2335 and D2394) provided on August 11, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 3, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that you were unaware a referral or prior authorization was required. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility and these services are not urgent or emergent, nor were they approved in advance.
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 on August 3, 2020, by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 7, 2019.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request.
The Plan says this claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for this service was not filed until October 22, 2020. This means that more than
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the
Plan does not have to pay for physician services provided to the enrollee on February 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthehospital outpatient visit (G0463) provided on May 28, 2020.You asked the Plan to pay forthe hospital outpatient visit. You say that you would like reconsideration because the right to recover for services rendered to eligible beneficiaries is notextinguished by plan regulation.The Plan denied your request. The Plan says this service has not been billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510.We find that CPT code G0463 is not supported in the record. Specifically, this claim was not billed with the required revenue code. Based on this information, we decided that Medicare rules for coverage of the hospital outpatient visit have not been met.Therefore, we decided that the Plan does not have to pay forthe hospital outpatient visit (G0463) provided on May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon October 7, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 did not pre-approve the physician's services.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 physician's servicesprovided on October 7, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray (71045) provided on July 8, 2020.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration because this claim denied as a duplicate in error.The Plan denied your request. The Plan says there no additional documentation supporting an additional study.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or providermust corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We find that CPT code 71045 is not supported in the record. Specifically, the submitted documentation does not show that the billing provider rendered a chest x-ray on July 8, 2020. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71045) provided on July 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound (76642) provided August 25, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that the services were medically necessary.The Plan denied your request. The Plan says the correct cost-sharing was 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 $100 copayment for ultrasounds. You have been asked to pay the Medicare allowed amount of $93.54 for the ultrasound. The allowable amount is less than the $100 copayment noted in the plan contract. 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 foran ultrasound (76642) provided August 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sleep study (95810, 95811).You asked the Plan to pre-approvea sleep study. You say that this is medically necessary.The Plan denied your request. The Plan says you do not have a covered indication for this test.The Plan must follow Medicare rules. Medicare rules say that polysomnography testing will only be covered if the patient demonstrates clinical evidence of one or more of the following conditions:Narcolepsy, Sleep apnea, Parasomnia, Other Respiratory Disorders, or Restless Legs Syndrome (RLS) and PLMD.We looked at the fileand Medicare rules.The submitted medical records do not show that you demonstrateclinical evidence of one or more of theconditions listed above. Based on this information, we decided that Medicare rules for coverage of a sleep study have not been met.Therefore, we decided that the Plan does not have to pre-approvea sleep study (95810, 95811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110).You asked the Plan to pre-approvethe dental item. You say that you went back multiple times for dentures adjustments due to pain. You say that you got a second opinion. You say that you were advised that you needed a new denture. You say that you paid out of pocket for your current dentures.The Plan denied your request. The Plansays 1 complete upper denture is covered once every 5 plan years. The Plan also says that the frequency limit for this item has been reached.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 limit of 1 complete upper denture every 5 plan years has been reached. The record shows that the Plan paid for a complete upper denture that you received on January 27, 2020.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020) and sphere, single vision, plano lens (V2100) provided on August 25, 2020.
You asked the Plan to pay for frames and lens. You say that the items should be covered. The Plan denied your request. The Plan says you purchased the items through a non-preferred provider.
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. There is a $25 copayment for $150 allowance every two years for eyewear when purchased through a preferred provider. We looked at the file and the Plan's rules. The items were purchased through a non-preferred provider. Based on this information, we decided that the Plan's rules for coverage of frames and lens have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020) and sphere, single vision, plano lens (V2100) provided on August 25, 2020.