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

We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447).

You asked the Plan to pre-approve this service. You say that a total knee arthroplasty is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was being treated for unilateral primary osteoarthritis of the left knee. She presented with left knee symptoms that have been present for approximately three months. The pain is moderate and she describes the symptoms as sharp and constant. She reports the problem is getting better. The symptoms are made worse with moving and there is swelling. There is difficulty with weight bearing activities such as getting up from a seated to standing position and ambulating. She uses a cane during ambulation. An exam of the left knee reveals minimal effusion. The knee is stable to varus/valgus stress with a negative anterior/posterior drawer test. There is moderate medial and lateral joint line tenderness to palpation. Active range of motion is 0-135. X-rays demonstrated bilateral knee moderate tricompartmental degenerative joint disease with associated joint space narrowing, subchondral sclerosis and osteophytic lipping.

However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. While documentation does support that the enrollee is not able to utilize non-steroidal anti-inflammatory drugs (NSAIDS); documentation does not support an inability to complete a course of reasonable physical therapy and/or viscosupplementation injections. In addition, evidence of a trial and failure of weight reduction has not been provided. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the doctor's office shouldn't have billed you and the bills should be paid by insurance. You say that you cannot afford to pay the bill. The Plan denied your request. The Plan says you must receive your care from a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the services provided are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require daily skilled services.

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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care.

Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the contraceptive services rendered.

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 Medicare covers specific preventive services only.

We looked at the file and Medicare rules. The services at issue are for contraceptive purposes. This is a preventive service that is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the contraceptive services rendered.

Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider.

You asked the Plan to waive the copayment for specialist services. You say that you were told these services were covered 100%. The Plan denied your request. The Plan says the correct copayment has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for physician/practitioner services/specialist.

The enrollee has been asked to pay a $40 copayment for specialist services. The total amount you are being asked to pay is $80 ($40 x 2 specialist visits = $80). Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider.

You asked the Plan to waive the copayment for a CT scan. You say that this copayment is way too high for a CT scan. You say that you do not remember paying this much in the past. The Plan denied your request. The Plan says the correct copayment has been 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 $325 copayment for outpatient diagnostic tests/diagnostic radiology services.

You have been asked to pay a $325 copayment for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/diagnostic radiology services 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 a CT scan provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 29828) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says procedure code 29828 is not supported by the medical records 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 29828 is "surgical shoulder arthroscopic biceps tenodesis."

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records submitted. Our coding reviewer found per the operative report - "the scope was then placed above the biceps tendon. There was some fraying of the Supraspinatus tendon. This was delicately debrided with the shoulder varying degrees of internal and external rotation, utilizing both the anterior and posterior portals. This was clearly a partial thickness defect." The operative report supports debridement. There is a more appropriate code to describe this service.

We looked at this coder's review, the file, and Medicare rules. 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 surgical services (CPT 29828) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249), surgical implant placement (D6010), a custom fabricated abutment (D6057) and an implant supported crown (D6066).

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental 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 pre-approve clinical crown lengthening (D4249), surgical implant placement (D6010), a custom fabricated abutment (D6057) and an implant supported crown (D6066).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Jardiance 25mg tablet medication.

You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial as this medication has been more effective for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Jardiance 25mg tablet medication.

Benefits for this medication 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee.

You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures. The Plan states they have paid for all emergent care up to the point of stability.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 post-stabilization care. Our physician reviewer found the review indicates that all inpatient care provided was not needed on an emergent basis. The enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility. The post-stabilization care services at the non-participating plan facility was not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 18 trips for routine transportation (A0120).

You asked the Plan to pre-approve the additional trips. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you have exhausted the allowable transportation benefit.

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 18 trips per year. 

We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 18 trips for routine transportation (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140), intraoral periapical x-ray (D0220), bitewing x-ray (D0270) and 2-dimensional oral photographic image (D0350).

You asked the Plan to pay for the dental services. You say that you were dissatisfied with the services provided and the length of time you had to wait for a scheduled appointment. You feel these services are costly and were provided when they were not necessary, and you should not be responsible for paying for them. The Plan denied your request. The Plan says problem-focused evaluations, intraoral periapical x-rays and 2-dimensional oral photographic images are not covered by Medicare or by the Plan's supplemental dental benefit. Bitewing x-rays are a covered service; however, they are limited to one set per calendar year. The Plan has already paid for your bitewing x-rays and therefore the benefit for this service has been exceeded.

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 or have exceeded the frequency allowed by the Plan. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140), intraoral periapical x-ray (D0220), bitewing x-ray (D0270) and 2-dimensional oral photographic image (D0350).

Your complaint about the care you received from a Plan-contracted provider 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider.

You asked the Plan to waive the copayment for ambulance services. You say that this copayment is too high. The Plan denied your request. The Plan says the correct copayment has been 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 $325 copayment for ambulance services.

You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for myocardial perfusion imaging.

You asked the Plan to waive the coinsurance for myocardial perfusion imaging. You say that you feel that the charges are unfair and the test was necessary. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for radiological diagnostic services provided in an outpatient hospital facility.

You received myocardial perfusion imaging. The total allowed amount is $1,215.17 and 20% of that is $243.03.

You have been asked to pay the total coinsurance amount of $243.03 for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for myocardial perfusion imaging.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916).

You asked the Plan to pay for the orthosis. You say that please find the attached documents and reprocess the claim towards payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and influenza virus vaccine administration (G0008).

You asked the Plan to pay for a Tdap vaccine and influenza virus vaccine administration. You say that this was billed correctly. The Plan denied your request. The Plan says these services cannot be paid as billed.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and influenza virus vaccine administration. The Plan follows the same rules. The rules also say that providers must report services correctly.

Records do not show that the enrollee was injured or directly exposed to any illness related to a Tdap vaccine and influenza virus vaccine administration. The records also do not support the billing of influenza virus vaccine administration. A Tdap vaccine was billed rather than an influenza vaccine, meaning that an administration of an influenza vaccine is not supported. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and influenza virus vaccine administration (G0008).

Benefits for a Tdap vaccine and influenza virus vaccine administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.