Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does not have to waive the copayment for the administration provided on September 20, 2021.  You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment for the administration. You say that you should have been informed of the charges beforehand. 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 20% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $20 copayment for specialist visits.  You received a Medicare Part B drug on September 20, 2021. The total allowed amount is $849.75 and 20% of that is $169.95.   You received the administration of a Medicare Part B drug on September 20, 2021. Therefore, you are responsible to pay the $20 copayment.   The total amount you owe is: $189.95.    You have been asked to pay the total amount of $189.95 for a Medicare Part B drug injection and the administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. The administration falls within the physician/practitioner services, including doctor's office visits 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 a Medicare Part B drug injection and does not have to waive the copayment for the administration provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).  You asked the Plan to pre-approve osseous surgery. You say that you need deep cleaning to try to avoid surgery. The Plan denied your request. The Plan says deep cleaning has been approved however, osseous is not covered under your 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 pre-approve osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 15, 2021 by an out-of-network (OON) provider.  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 were rendered by an out-of-network provider without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 laboratory services provided on September 15, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bracket assy footplate outside edge (K0108) for a
wheelchair.
You asked the Plan to pre-approve the item. You say that the wheelchair is in need of repair. The Plan denied
your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a bracket assy footplate outside edge (K0108) for a
wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Encore bed and accessories.
You asked the Plan to pre-approve the Encore bed and accessories. You say that you would like
reconsideration because the member is not able to turn or get out of bed due to their condition. The Plan denied
your request. The Plan says this is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the Encore bed and
accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home delivery meals.  You asked the Plan to pre-approve home delivery meals. You say that you have heart failure issues and feel you should qualify for home delivered meals. The Plan denied your request. The Plan says your discharge diagnosis was not congestive heart failure.  The Plan contract offers a supplemental meals benefit. The Plan covers meals following discharge from a hospital due to congestive heart failure,  We looked at the file and the Plan's rules. The file shows that your discharge diagnosis was not congestive heart failure. Based on this information, we decided that the Plan's rules for coverage of home delivery meals have not been met. Therefore, we decided that the Plan does not have to pre-approve home delivery meals.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for custom abutments (D6057) and abutment-supported crowns
(D6058) provided on October 13, 2021.
You asked the Plan to pay for the dental services. You say that these services were medically necessary, and
you were told crowns are covered by your benefit. The Plan denied your request. The Plan says these services
are not covered by your dental benefit. In addition, while some crowns are covered, only specific codes for
these services are eligible.
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 custom
abutments (D6057) and abutment-supported crowns (D6058) provided on October 13, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a RhinAer procedure (intranasal radiofrequency
ablation).
You asked the Plan to pre-approve a RhinAer procedure. You say that the requested service is a medical
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met for the
requested service.
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 RhinAer procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is insufficient high-quality, peer-reviewed evidence to support the use of
intranasal radiofrequency ablation over other available therapies.
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 RhinAer procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a RhinAer procedure (intranasal radiofrequency ablation).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary. The enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.  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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (80307) provided on July 1, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request.
The Plan says that this exceeds the frequency limitation for this service.
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 rules also say that it is not appropriate to report more than twelve (12) presumptive urine drug
testing (UDT) (code 80305, 80306, or 80307) services per calendar year.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Although the Plan states that the testing at issue was denied due to frequency,
the Plan has not provided any documentation showing when the enrollee previously received this testing.
Therefore, we decided that the Plan has to pay for drug testing (80307) provided on July 1, 2021.
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 subsequent hospital care (99233) provided on July 22, 2021.  You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier.  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, we have confirmed that code 99233 is a column II code to column I code 33208. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on July 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tyvaso solution (J7686).  You asked the Plan to pre-approve Tyvaso solution. You say that this medication is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that Tyvaso (J7686) is subject to the criteria listed in the Medicare rules section.   We looked at the file and Medicare rules. In this case, Tyvaso is being prescribed for an enrollee with pulmonary artery hypertension that is secondary to stage IV sarcoidosis and interstitial pulmonary fibrosis. As this is secondary to disorders of the respiratory system, the criteria for coverage of Tyvaso have not been met. Based on this information, we decided that Medicare rules for coverage of Tyvaso solution have not been met. Therefore, we decided that the Plan does not have to pre-approve Tyvaso solution (J7686).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor provided on June 4, 2021.  You asked the Plan to pay for the services provided. You say that the records support the service. The Plan denied your request. The Plan says the documentation did not contain a signed physician order.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation does not indicate the enrollee has had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. The lab results and medical records do not include a log that shows testing frequency or results. The records do not show the adjustments made to the insulin dosage. 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 continuous glucose monitor provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator provided from July 7, 2021, to September 30, 2021.  You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you were never informed of how high the charges were. 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 20% coinsurance for (DME and related supplies.   You received an automatic external defibrillator from July 7, 2021, to September 30, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.   Date of Service Service Allowed Amount Amount You Owe 7/7/2021 An Automatic External Defibrillator  $2,931.45 $586.29 8/30/2021 An Automatic External Defibrillator $2,931.45 $586.29 9/30/2021 An Automatic External Defibrillator $2,931.45 $586.29  The total amount you owe is: $1,758.87.   You have been asked to pay the total coinsurance amount of $1,758.87 for an automatic external defibrillator. An automatic external defibrillator falls within the DME and related supplies 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 an automatic external defibrillator provided from July 7, 2021, to September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services coded 64494 provided on June 22, 2021.  You asked the Plan to pay for 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 billed are not payable.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64494 provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on July 6, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that anything related to the coronavirus would be fully covered. 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 20% coinsurance for DME and related supplies.   You received DME and related supplies on July 6, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $66.50 and 20% of that is $13.30.  You have been asked to pay the total coinsurance amount of $13.30 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided on July 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on July 20, 2021.  You asked the Plan to pay for the hospital discharge day management. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says under Medicare guidelines Original or Traditional Medicare is responsible for payment from the day the enrollee revokes hospice until the start of the next month after revocation.  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 for the hospital discharge day management (99239) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), adjunctive pre-diagnostic test (D0431), and caries susceptibility test (D0425) provided on September 9, 2021.  You asked the Plan to pay for the dental services. You say that your regular dentist office was closed due to the pandemic. You say that when they opened it was difficult to get an appointment. You say that you had to start over with a new dentist. You also say that these services should be covered because you paid for dental coverage for 2 years but did not use it due to the pandemic. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan says that the frequency limits have been exceeded. The Plan also says that the adjunctive pre-diagnostic test and the caries susceptibility test are not listed as covered services.  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 and the comprehensive oral evaluation and complete series x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on February 19, 2020. Additionally, the adjunctive pre-diagnostic test and the caries susceptibility test are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), adjunctive pre-diagnostic test (D0431), and caries susceptibility test (D0425) provided on September 9, 2021.