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

 We decided that the Plan does not have to waive the copayment for the emergency room services provided on July 6, 2021  You asked the Plan to waive the copayment for the emergency room services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  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 $90 copayment for Emergency care.     We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on July 6, 2021. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services 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 copayment for the emergency room services provided on July 6, 2021
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 4, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.  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 an $80 copayment for Emergency care.   We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room services on August 4, 2021. You have been asked to pay an $80 copayment for the emergency room visit. The emergency room visit falls 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 copayment for the emergency room visit provided on August 4, 2021.   Your complaint about not being treated is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), and an abutment supported crown (D6058) provided by a participating provider.

You asked the Plan to pay for a custom fabricated abutment and an abutment supported crown. You say that this dental work is necessary. The Plan denied your request. The Plan says the requested services are not a covered dental benefit.

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 a custom fabricated abutment (D6057), and an abutment supported crown (D6058) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the maxillary immediate denture (D5130), mandibular immediate denture (D5140), simple extractions (D7140), surgical extractions (D7210), and alveoloplasties in conjunction with extractions (D7310 and D7311) provided on May 21, 2021 by an out-of-network (OON) provider.    You asked the Plan to pay more for the maxillary and mandibular immediate dentures, extractions, and alveoloplasties. You say that the dentist sent in a pre-estimate which the Plan approved. You also say that you would like the Plan to do the right thing and pay this bill because you have no extra money. The Plan denied your request. The Plan says these services were performed by an OON provider and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for these services. The Plan also says that you did not contact the Plan prior to this date of service to verify OON benefits for extractions and dentures.  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, you are responsible for a 55% coinsurance for each extraction, and a 75% coinsurance for each immediate denture and oral surgery service. You are also responsible for the difference between the billed amount and allowed amount because these services were rendered by an OON provider. Therefore, we decided that the Plan does not have to pay more for the maxillary immediate denture (D5130), mandibular immediate denture (D5140), simple extractions (D7140), surgical extractions (D7210), and alveoloplasties in conjunction with extractions (D7310 and D7311) provided on May 21, 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 Transcutaneous Electrical Nerve Stimulator (TENS) unit (E0730).  You asked the Plan to pre-approve the TENS unit. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that TENS therapy for Chronic Low Back Pain (CLBP) will be denied as not reasonable and necessary.  We looked at the file and Medicare rules. The requested unit is for the treatment of back pain. This is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator (TENS) unit (E0730).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on May 20, 2021.  You asked the Plan to pay for the transportation services. You say that the transportation services were necessary. The Plan denied your request. The Plan says the non-emergency transportation services were not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for the enrollee on May 20, 2021. Supervision could be provided with one of these other transportation methods. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on May 20, 2021. The reviewer also found that the documentation does not support that the ambulance transport on May 20, 2021, was medically reasonable and necessary for the 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 the transportation services have not been met. Specifically, the file does not show that other means of transport (such as stretcher van, wheelchair van) were contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on May 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76705) provided on August 18, 2021.  
You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  

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 76705 is a column II code to column I code 93976. 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 ultrasound services (76705) provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions (D7210) provided on July 22, 2021.

You asked the Plan to pay more for the extractions (D7210). You say that you paid $3,030 up front and was
informed the dental plan would pay 50%. You say that you were not told the provider was not in-network and
you were not reimbursed half. The Plan denied your request. The Plan says the claim processed correctly
toward your out-of-network 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 Plan is only obligated to pay 50%
of the allowed amount for each extraction. You are responsible for the charges above what the plan pays to the
out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the extractions
(D7210) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable home ventilator (E0466) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the ventilator. You say that the medical records provided support the necessity of the requested service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve portable home ventilator (E0466) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 50 hours of services of a home health aide (HHA) (G0156) and direct skilled nursing services of a registered nurse (RN) (G0299).  You asked the Plan to pre-approve 50 hours of HHA services and direct skilled nursing services of a RN. The Plan denied your request. The Plan says the enrollee no longer qualifies for 50 hours of HHA services.    The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 50 hours of HHA services and direct skilled nursing services of a RN. Our reviewer says that HHA services are not medically necessary, reasonable, or coverable. Our physician reviewer found the enrollee does not have documented skilled nursing needs. Our reviewer found that the enrollee does not have documented skilled therapy needs.  The enrollee is functionally mobile and living with a caregiver. Our physician reviewer also found that while the enrollee is forgetful and needs supervision for safety, the enrollee does not have skilled needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 50 hours of HHA services and direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 50 hours of services of a home health aide (HHA) (G0156) and direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat elevator feature for a power wheelchair (E2300).  You asked the Plan to pre-approve the seat elevator feature. You say that the feature is medically necessary. The Plan denied your request. The Plan says this feature is non-covered under Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered.  We looked at the file and Medicare rules. The requested seat elevator is not eligible for Medicare coverage. Based on this information, we decided that Medicare rules for coverage of the seat elevator feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevator feature for a power wheelchair (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the local anesthesia (D9215) provided on July 1, 2021
  
You asked the Plan to pay for the local anesthesia. You say that this service was necessary, and you believe it should be covered. 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 local anesthesia (D9215) provided on July 1, 2021
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilizing device (22869).  You asked the Plan to pre-approve the insertion of stabilizing device. You say that by not providing coverage, the Plan is out of compliance with Medicare guidelines. You say that your patient is a good candidate because they meet all the approved indications, and the treatment is considered safe and effective. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of this health problem.  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 insertion of stabilizing device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the records provided are insufficient to determine whether the enrollee's condition satisfies the coverage criteria, and the requested service cannot be recommended.  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 insertion of stabilizing device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilizing device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital readmission from December 30, 2020, to January 2, 2021.  

You asked the Plan to pay for the inpatient readmission. You say that the readmission was unavoidable. The Plan denied your request. The Plan says payment for these services was included in the initial hospital stay.  

The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically necessary, and if the readmission did not result from a premature discharge from the same hospital. 

 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 inpatient readmission. Our reviewer says that the inpatient is not medically necessary. Our physician reviewer found the provided documentation indicates that the readmission was necessary due to the risk of worsening sepsis and development of endocarditis if there was Augmentin resistance. The reviewer also found that the readmission resulted from a premature discharge from the same hospital as culture results were not fully ready and the results changed the hospital needs. Therefore, the reviewer found that the two admissions should be combined.  

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 inpatient readmission have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital readmission from December 30, 2020, to January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the specialist visit and walking boot (99203 and L4361) provided on August 13, 2021.  You asked the Plan to waive the cost share for the specialist visit and walking boot. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit and a walking boot on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.  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 specialist services and a 20% coinsurance for durable medical equipment.   We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit and a walking boot on August 13, 2021. You have been asked to pay a $50 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioners services benefit category. You have also been asked to pay a 20% coinsurance for the walking boot. The walking boot falls within the Durable medical equipment benefit category. This means that you have been asked to pay the correct amounts 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 share for the specialist visit and walking boot (99203 and L4361) provided on August 13, 2021.   Your complaint about how the provider's office handled your situation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).  You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.  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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.   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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy, with biopsy (43239, 82947, 88305, 93005, 43259) provided on August 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an esophagogastroduodenoscopy, with biopsy. You say that the authorization on file is for a different code. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan 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 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 an esophagogastroduodenoscopy, with biopsy (43239, 82947, 88305, 93005, 43259) provided on August 19, 2021 by an out-of-network (OON) provider.