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

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
for the enrollee.

You asked the Plan to pre-approve a CGM. You say that the Freestyle Libre is medically necessary. The Plan
denied your request. The Plan says that the enrollee does not meet criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation provided on January 11, 2021.
You asked the Plan to waive the copayment for the telephone evaluation. You say that your saw your primary care physician for an annual physical but was charged for a telehealth visit. You say that the annual physical copayment is $0. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 for an annual physical. If you receive services that address a medical condition during the same office visit, you pay a $10 PCP office visit copayment. You have been asked to pay a $10 copayment for the telephone evaluation. The telephone evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that hypertension, back pain and atrial fibrillation were discussed during the visit. 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 telephone evaluation provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on January 4, 2021.

You asked the Plan to pay for the dental service. You say that the build up with pins was absolutely necessary and not optional. You say that you needed this service to secure the crown in place. You say that if the core build up had not been done, the crown would not remain intact for the long term. You also say that this service should be covered. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that there is no record that you contacted the Plan prior to the date of service to verify benefits or provider eligibility.

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 core build up (D2950) provided on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 10, 2020 to January 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the records do not support the billed DRG and diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871 and diagosis code A41.9 (sepsis, unspecified organism). 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 these services. Our reviewer says that the records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee presented to the hospital with wheezing and hypoxia that improved with bronchodilators. She was diagnosed with sepsis, pneumonia, and COPD exacerbation. The billed DRG 871 and associated diagnosis code of A41.9 (sepsis, unspecified organism) are not sufficiently supported in the notes, as there was no clear indication of end organ damage associated with the infection and blood pressure was normal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from January 10, 2020 to January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) routine venipuncture (36415)
You asked the Plan to pay for the office visit. You say that you originally submitted the claim on 09/18/2019 within timely filling guidelines. Please review for possible payment. The Plan denied your request. The Plan says the claim was submitted past the timely filing limitation.
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 the office visit was not filed until January 15, 2021. 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 the outpatient office visit (99213) routine venipuncture (36415)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99203) radiologic examination, spine, lumbosacral (72100) provided October 16, 2020
You asked the Plan to pay for the chiropractic services. You say that please reconsider the claim for exam and x-ray totaling $350.00 and pay this doctor. You are a senior citizen and on limited funds. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99203) radiologic examination, spine, lumbosacral (72100) provided October 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for incision procedures on the hand and fingers (26055) provided June 24, 2020.

You asked the Plan to pay for the surgical procedure. You say that the surgical assistant was chosen by the operating surgeon completely at surgeon's discretion and the surgical assistant provider had no choice to be o the case and ethically could not deny the services to the enrollee. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for the procedure performed.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 26055. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for incision procedures on the hand and fingers (26055) provided June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair for the enrollee.
You asked the Plan to pre-approve a shower chair. You say that the patient is at high risk for falling. The Plan denied your request. The Plan says that this is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visits provided on September 8, 2020 to October 13, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the rest home visits. You say that you did not know the enrollee switched plans, and you were unaware prior authorization was needed. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 rest home visits provided on September 8, 2020 to October 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for carpal tunnel release surgery (64721) trigger finger injection (26055) provided August 3, 2020

You asked the Plan to pay for the surgical procedure. You say that the primary surgeon requested services from assistant surgeon because he felt that it was in the best interest of the enrollee. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 64721 and 26055. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for carpal tunnel release surgery (64721) trigger finger injection (26055) provided August 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 4, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was a physical not an outpatient visit. The Plan denied your request. The Plan says the medical records show that the reason for the office visit was to discuss multiple medical problems.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Physician Services. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the Physician Services benefit category. The medical record shows multiple medical problems were discussed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant (D6010) provided on December 15, 2020.
You asked the Plan to pay for an implant. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an implant have not been met. Specifically, services were provided by an Opt out provider. The Plan does not cover dental services when provided by an Opt out provider. Therefore, we decided that the Plan does not have to pay for an implant (D6010) provided on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for non-surgical treatment of a hip fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on August 24, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on August 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from August 4, 2020, through August 18, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan with limited exceptions, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 physical therapy 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 physical therapy services provided from
August 4, 2020, through August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on December 3, 2020.

You asked the Plan to pay for the dental service. You say that the dental office advised that prior authorization was not needed as you would be having a routine cleaning. You say that told them you could not have anything done that would not be covered by your insurance. You say that you received a bill for $76. You say that now that you are a periodontal patient, nothing is covered. You also say that you cannot afford to pay the bill, or future bills, just for the dentist to check your mouth. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
December 8, 2020.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says that the Plan paid $100, which is the eyewear benefit allowance.
Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid $100, which is the Plan's eyewear benefit allowance. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) for tooth #30 provided on December 29, 2020.

You asked the Plan to pay for the crown. You say that you feel that this service should be covered. The Plan denied your request. The Plan says the maximum allowed for this procedure has been met.

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, crowns are limited to once per tooth every five years. The record shows that you received a crown (D2740) on tooth #30 on November 14, 2017 and your crowns benefit for tooth #30 has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth #30 provided on December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exchange/replacement of a prosthetic intraocular lens (IOL).

You asked the Plan to pre-approve the IOL exchange procedure. You say that it is felt that this should be covered to improve your visual function. The Plan denied your request. The Plan says this service cannot be covered by Medicare as the requested IOL is not shown to be more effective than the current type of lens.

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 IOL exchange procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has previously had cataract surgery with intraocular lens placement. The enrollee has vision impairments that interfere with activities of daily living. The record indicates that she prefers glasses for distance and would like an IOL for up close vision. The medical records do not support the medical necessity and reasonableness of the requested service as defined by Medicare rules.

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 IOL exchange procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve exchange/replacement of a prosthetic intraocular lens (IOL).