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

We decided the Plan does not have to pre-approve tertiary level dermatology services out of network for the
enrollee.

You asked the Plan to pre-approve these services. You say that this service should be approved for the enrollee.
The Plan denied your request. The Plan says the enrollee was approved to see an in-network provider. Maximus 
overturned the Plans denial stating the care was medically necessary. The Plan requested a reopen
and stated there was no documentation that this care could not be provided in network and it was approved in
network without issue.

The Plan is correct in this case. Medicare rules say that plans can require enrollees to get care from network
providers. The contract with the Plans states enrollees must use network providers. The Plan had approved this
care in network. The requested provider is not a network provider.

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 tertiary level dermatology services out of network for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L3170, L1971) provided to the enrollee on December 19, 2020.
You asked the Plan to pay for foot orthotics. You say that the services were provided based on the prescription and the notes received from the doctor. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for orthotics (L3170, L1971) provided to the enrollee on December 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 22, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 4, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is out-of-network.
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 lab work provided on December 4, 2020 by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on May 5, 2021.

You asked the Plan to pay an additional amount for a periodic oral evaluation, and a teeth cleaning. You say that the out-of-network provider is closer to you. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.

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 a periodic oral evaluation, and a teeth cleaning have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the bed. You say that you cannot use a manual crank and need to be able to adjust the height of the bed. The Plan denied your request. The Plan says this is not a 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 a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on May 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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the rollator walker (E0143) and the miscellaneous durable medical equipment (E1399) rendered by the out-of-network (OON) provider on
January 15, 2021.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items were rendered by an out of network provider, who is not certified to participate in Medicare.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees can receive care from either a network provider or an out-of-network provider, but the provider must be eligible to participate in and has not opted out of Medicare.

We reviewed the case file and the Plan's rules. The provider in this case is not a network provider with the Plan. The Plan contract however states that enrollees can receive care from either a network provider or an out-of-network provider, but the provider must be eligible to participate in Medicare. The provider in this case is not a certified Medicare provider. Therefore, we decided that the Plan does not have to issue reimbursement for the rollator walker (E0143) and the miscellaneous durable medical equipment (E1399) rendered by the out-of-network (OON) provider on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit rendered on September 18, 2019.
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 procedure code 99347 is not supported.
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 99347 is Level 1 home visit for the evaluation and management of established patient with minor and/or self-limited problem, including problem-focused interval history and physical examination, and straightforward medical decision-making, typical time with patient 15 minutes. We find that CPT code 99347 is not supported in the medical record. Specifically, the records do not support
that a physician or physician practitioner was present to render the services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home visit rendered on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fillings (D23331 x2) provided on March 29, 2021.
You asked the Plan to pay for fillings. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for fillings (D23331 x2) provided on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergent transportation trips

You asked the Plan to pre-approve the additional trips. You say that this is needed for dialysis three times a week. The Plan denied your request. The Plan says additional trips cannot be covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. The trip log shows that 9/20 trips have been used for this calendar year. You have 11 trips left according to your contract and the trip log.

Additional trips cannot be requested beyond twenty for the year. Therefore, we decided that the Plan does not have to pre-approve additional non-emergent transportation trips
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with an out of network dentist.

You asked the Plan to pre-approve the dental services. You say that all of the in-network dentists say the same thing to everyone. You say that they do not deal with the actual issues. You also say that you want these services to be covered as in network. The Plan denied your request. The Plan says dental services that you receive from an out of network are not covered. The Plan also says that there are in network dentists available.

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 services when the services are medically necessary and reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, dental services must be provided in network to be covered. Additionally, the Plan confirmed that there are in network dentists available. Therefore, we decided that the Plan does not have to pre-approve dental services with an out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the neurostimulator implantation services provided by provided on July 22, 2020.

You asked the Plan to reduce the cost for the neurostimulator implantation services. You say that insurance was active for this date of service and the patient responsibility should not be that high. You say that you were quoted $350 for the same procedure and you cannot afford over $4,000. The Plan denied your request. The Plan says the cost share 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 a $325 for each in-network, Medicare-covered outpatient hospital facility visit. If you get Part D Medicare-covered self-administered drugs in an outpatient setting, they may be covered under your prescription drug benefit on this plan. Your contract with the Plan also clearly says that you must pay 20% for Medicare-covered equipment and supplies from an in-network provider, 20% for each Medicare-covered Part B drug obtained at an in-network provider's office or outpatient setting, $20 per day, per in-network provider, for Medicare-covered x-ray services and $10 per day, per in-network provider, for Medicare-covered lab services.

You have been asked to pay a total of $4,957.69 for the neurostimulator implantation services.

The neurostimulator implantation falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The neurostimulator parts fall within the "Durable medical equipment (DME) and related supplies" benefit category. The Part B Drugs fall within the "Medicare Part B prescription drugs" benefit category. The laboratory test and x-ray fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The self-administered drugs are not covered under your Part B benefit.

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 reduce the cost for the neurostimulator implantation services provided by provided on July 22, 2020.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 4, 2021, to March 1, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee came home worse off than when they went into the facility and they have non-healing bed sores from the stay. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $100 copayment for days 21-100 for SNF care. 

The enrollee had a SNF stay from February 4, 2021, to March 1, 2021. They are not being charged a copayment for days 1-20 (February 4, 2021, to February 23, 2021). The enrollee is responsible to pay a $100 copayment for days 21-25 (February 24, 2021, to February 28, 2021). However, they are only being asked to pay $400, which is less than the total copayment amount. 

The enrollee has been asked to pay $400 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from February 4, 2021, to March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 6, 2021.

You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate for providers to report modifier 57 with an evaluation and management service when a planned procedure is being performed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 99232-25-57 is not supported in the record. Specifically, the record indicates that the major surgery was a planned procedure. There is no indication that the billed evaluation and management visit resulted in the initial decision to perform surgery. It is not appropriate to report modifier 57 in this instance. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves (L2397) purchased November 13, 2020.

You asked the Plan to pay for the knee orthoses and suspension sleeves. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says the medical reasonableness of the purchased times has not been established.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthoses and suspension sleeves. Our reviewer says that the purchased items were not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthoses and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves (L2397) purchased November 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer device.

You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The Plan says this is 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 the Superion interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer remains experimental. More research is needed to show safety and efficacy of the spacer. 

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 Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).

You asked the Plan to pre-approve an upper partial denture, and a lower partial denture. You say that the services are necessary. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of one every 5 Plan years.

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 upper partial denture, and a lower partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for these services on March 19, 2020. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial denture (D5214).
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 the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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.
Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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.