Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313)
and electronic connection (E2311) and a seat elevation system (E2300).
You asked the Plan to pre-approve an expandable controller with harness and electronic connection and a seat
elevator. You say that the requested items are a medical necessity for the enrollee. The Plan denied your
request. The Plan says rules for coverage have not been met because the requested items 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 an expandable controller with harness
and electronic connection and a seat elevator. Our reviewer says that the requested items are not considered
medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation
that the enrollee meets Medicare criteria for an expandable controller with harness and electronic connection.
Records document that the enrollee has 4/5 upper extremity strength and is independent with feeding and
dressing, thus indicating the ability to control the power options with their own switches.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been
met. A seat elevator is not Medicare covered. Therefore, we decided that the Plan does not have to pre-approve
an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) and a seat elevation
system (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on July 9, 2020.
You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0483) provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 4, 2021, and the intraoral - periapical first radiographic image (D0220) provided May 10, 2021.

You asked the Plan to pay for the limited oral exam and intraoral x-rays. You say that the dental services were necessary because you were in pain and your dentist initially x-rayed the wrong tooth. The Plan denied your request. The Plan says the limited oral exam is not a covered service and you have exceeded frequency limits for the intraoral x-rays.

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. The Plan covers intraoral x-rays once per calendar year.

We looked at the file and Medicare rules. The Plan provided documentation showing that intraoral x-rays were previously covered on May 4, 2021. The Plan contacted the provider who indicated the original x-ray was for a different issue and was not done in error. Based on this information, we determined that the Plan's frequency limit for the intraoral x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the limited oral exam is not among those covered services. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 4, 2021, and the intraoral - periapical first radiographic image (D0220) provided May 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system supplies.
You asked the Plan to pre-approve Omnipod disposable insulin pump system supplies. You say that the services are necessary. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Omnipod disposable insulin pump system supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Omnipod disposable insulin pump system supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible, copayment and coinsurance for an office visit, ophthalmic diagnostic imaging, and Medicare Part B drugs provided from January 16, 2020, to April 6, 2021. You asked the Plan to waive the deductible, copayment and coinsurance for an office visit, ophthalmic diagnostic imaging, and Medicare Part B drugs. You say that you disagree with the increase in charges. 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. Your contract with the Plan says that there is a $200 deductible. Your contract with the Plan also clearly says that there is a $30 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs and outpatient diagnostic tests and therapeutic services and supplies. You received an office visit, ophthalmic diagnostic imaging, and Medicare Part B drugs from January 16, 2020, to April 6, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service(s)
Allowed Amount
Amount You Owe
1/16/2020
99213
$54.20
$33.37 (deductible)
1/16/2020
99213, 67028
$112.57
$30 (copayment)
1/16/2020
92134
$45.20
$9.04
1/16/2020
J9035
$88.71
$17.74
2/13/2020
92134
$45.20
$9.04
2/13/2020
J9035
$88.71
$17.74
10/15/2020
92134
$45.20
$9.04
10/15/2020
J9035
$84.00
$16.80
1/8/2021
99213, 92134, 67028, J9035
$275.14
$200 (deductible)
1/8/2021
J9035
$75.14
$15.03
2/5/2021
92134
$45.20
$9.04
2/5/2021
J9035
$66.14
$16.53
3/5/2021
92134
$45.20
$9.04
3/5/2021
J9035
$66.14
$16.53
4/6/2021
92134
$45.20
$9.04
4/6/2021
J9035
$66.14
$16.53
The total amount you owe is: $434.51. The items or services you asked the Plan to waive the deductible, copayment and coinsurance for fall within the benefit categories: physician/practitioner services, including doctor's office visits, Medicare Part B prescription drugs, and outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 deductible, a $30 copayment for specialist visits, 20% coinsurance for Medicare Part B drugs and outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an office visit, ophthalmic diagnostic imaging, and Medicare Part B drugs were received on January 6, 2020 to April 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible, copayment and coinsurance for an office visit, ophthalmic diagnostic imaging, and Medicare Part B drugs provided from January 16, 2020, to April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a tangential biopsy of skin (11102) provided on January 14, 2021, and an injection of a single tendon sheath or ligament (20550) provided on March 1, 2021, in an outpatient hospital setting.
You asked the Plan to waive the copayments for a tangential biopsy of skin and an injection of a single tendon sheath or ligament. You say that you are disputing the copayments for the services at issue. The Plan denied your request. The Plan says the correct copayments were 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $166.77 copayment for a tangential biopsy of skin and a 242.59 copayment for an injection of a single tendon sheath or ligament. A tangential biopsy of skin and an injection of a single tendon sheath or ligament fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay less than or equal to the full and 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 a tangential biopsy of skin (11102) provided on January 14, 2021, and an injection of a single tendon sheath or ligament (20550) provided on March 1, 2021, in an outpatient hospital setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Group 3 power wheelchair (PWC) and accessories rendered on February 4, 2021.
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 are not covered.
The Plan must follow Medicare rules. The rules say that if the coverage criteria are not met, the KX modifier must not be used. We looked at the file and Medicare rules. The file shows that the services were billed with the -KX modifier, indicating that the criteria are not met. Therefore, we decided that the Plan does not have to pay for the Group 3 power wheelchair (PWC) and accessories rendered on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 14, 2021.

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 are not covered.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply. 

We looked at the file and Medicare rules. Billed procedure codes 80048 (basic metabolic panel) and 85027 (complete blood count) have a PC/TC indicator of 9 and no PC or TC payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation, establish patient (D0120) provided March 3, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the dental cleaning and periodic oral exam. You say that this was a basic dental checkup and cleaning and you would like the services covered. The Plan denied your request. The Plan says these services are not covered when provided OON.

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. The Plan covers the dental cleaning and periodic oral exam when the services are rendered by a network provider.

We looked at the file and Medicare rules. 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 pay for these services. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning and periodic oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and periodic oral evaluation, establish patient (D0120) provided March 3, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on March 30, 2021.

You asked the Plan to pay for the acupuncture services. You say that the enrollee has coverage for acupuncture for chronic pain. The Plan denied your request. The Plan says the provider is not supervised by any physician, physician assistant or nurse practitioner or clinical nurse specialist.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services were provided by auxiliary personnel, licensed acupuncturist. There is no evidence of supervision. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 29, 2021 to January 31, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary and should be covered. The Plan denied your request. The Plan says that the criteria are not met for the dates in question, and the inpatient care was not medically necessary. The services could have been provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on January 29, 2021, and was then admitted to the hospital and treated. On January 31, 2021, the enrollee's condition stabilized and improved, and they were discharged back to the facility once considered medically stable. The review indicates that the record showed that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 29, 2021 to January 31, 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 services (99050, 99070) provided on August 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are bundled services.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Codes 99050 and 99070 are assigned a status indicator of "B" under the Physician Fee Schedule, which means that these are bundled service. Payment for these services is bundled into payment for other services. No separate payment can be made for these codes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99050, 99070) provided on August 16, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from February 1, 2021, to February 28, 2021.
You asked the Plan to pay for SNF care. You say that this was billed correctly. The Plan denied your request. The Plan says that this was not billed with the authorized Health Insurance Prospective Payment System (HIPPS) rate code.
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. We find that the Plan did not submit a compelling denial rationale in this case. The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the SNF services were authorized with a HIPPS code that was calculated at the time that the approval was requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the enrollee's actual condition and the services actually rendered during the statement period of the claim. It would therefore be expected that the billed code would differ from a code that was estimated prior to the services being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are incorrect or not supported, only that the code, as a whole, was not approved. We find that this denial of payment has not been substantiated. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided from February 1, 2021, to February 28, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network
services are not covered.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. 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 the services provided by an out-of-network provider on February
23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs (J3490) provided on September 14, 2020.

You asked the Plan to pay for drugs. You say that this should be covered. The Plan denied your request. The
Plan says records for this date of service have not been submitted.

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 J3490 is unclassified drugs.

We find that CPT code J3490 is not supported in the medical record. Specifically, no medical records for this
date of service have been submitted. Without this information, this code cannot be verified. Based on this
information, we decided that Medicare rules for coverage of drugs have not been met. Therefore, we decided
that the Plan does not have to pay for drugs (J3490) provided on September 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.