Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy for a molar (D3330).

You asked the Plan to pay for the dental service. You say that this service was for a root canal. You say that the literature that you have states that the plan covers needed root canals. You also say that yours was needed as you had pain and swelling. The Plan denied your request. The Plan says endodontic therapy for a molar is not listed as a covered service. The Plan also says that any services not listed are not covered.

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 endodontic therapy for a molar (D3330).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services rendered were not urgent, emergent or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray, shoulder x-ray, and hip x-ray.

You asked the Plan to pay for the x-rays. You say that the enrollee was not under hospice care at the time she was admitted to the hospital on this date of service. The Plan denied your request. The Plan says the Medicare Hospice benefit, through fee-for-service Medicare, covers all Hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for service Medicare also covers attending physician services and all care unrelated to the terminal illness starting on the date of the Hospice election until the first day of the month following the month in which Hospice is revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the chest x-ray, shoulder x-ray, and hip x-ray.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045).

You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says there is no additional documentation supporting an additional study which was billed and remains denied.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 71045 is not supported in the record. Specifically, the record indicates that three units of this service were approved and paid by the Plan. The documentation submitted does not indicate that an additional study was rendered. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the post cataract laser surgery (66821).

You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $335 copayment for each Medicare-covered outpatient hospital facility visit.

You have been asked to pay a $335 copayment for the Medicare-covered outpatient surgery provided. 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 issue reimbursement of the copayment for the post cataract laser surgery (66821).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing.

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. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on October 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that these services are provided at the request of the 
referring provider. The Plan denied your request. The Plan says prior authorization was not obtained by a 
participating provider. 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 services provided on October 20, 2020 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0482).

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 80307 and G0482 is not supported in the record. Specifically, this claim was billed with a laboratory place of service code while the records indicate that the face-to-face encounter was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0482).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extracorporeal photopheresis (36522).

You asked the Plan to pay for extracorporeal photopheresis. You say that this was medically necessary. The Plan denied your request. The Plan says the criteria for coverage were not met.

The Plan must follow Medicare rules. Medicare rules say that Medicare provides coverage for extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study.

We looked at the file and Medicare rules. While the record shows that the enrollee had BOS, it does not show that the enrollee had a lung allograft transplantation. Based on this information, we decided that Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the Plan does not have to pay for extracorporeal photopheresis (36522).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens upgrades (V2784, V2781, V2755, V2750).

You asked the Plan to pay for lens upgrades. You say that you were not aware the upgrades would not be
covered. The Plan denied your request. The Plan says these upgrades are not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine eye exam every year and up to $200 for eyeglasses (frames and lenses)
or up to $200 for contact lenses every two years.

We looked at the file and the Plan's rules. The Plan's supplemental benefit does not include lens upgrades.
Based on this information, we decided that the Plan's rules for coverage of lens upgrades have not been met.
Therefore, we decided that the Plan does not have to pay for lens upgrades (V2784, V2781, V2755, V2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330).

You asked the Plan to pay for the dental services. You say that you switched dentists after your appointment in February because you were not satisfied with the services that you received. You say that this was your first appointment with this provider. You also say that you received another comprehensive oral evaluation and panoramic x-ray again. The Plan denied your request. The Plan says comprehensive oral evaluations and panoramic x-rays are covered once every 3 years. The Plan also says that the frequency limits for these services have 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 frequency limits for comprehensive oral evaluations and panoramic x-rays have been exceeded. The record shows that the Plan paid for these services which you received. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment 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 there is a $175 copayment per day for days 1-8. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay there is a $175 copayment per day for days 1-6 for an inpatient hospital stay. The total amount you are being asked to pay is $1,050 ($175 x 6 days = $1,050). The correct copayment has been applied to the services that were provided. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy 
electrical pump (NPWT) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says consideration for other wound care such as dressing changes, hyperbarics, wound care 
clinic, and possible surgical intervention can be considered as an alternative. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee continues to need the 
negative pressure wound therapy pump services. The negative pressure wound therapy pump has been used for 
four months with no records documenting a medical rationale for continued use of this device over other 
wound therapy modalities. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a negative pressure wound therapy electrical pump (NPWT) for the 
enrollee.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the enrollee required minimal assistance to sit up, lie down, stand up, and sit down. 
The enrollee required minimal assistance times two to stand at walker. The documentation does not support 
that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 
The enrollee's care needs can be met at a lower 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.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the enrollee was admitted to the hospital for encephalopathy, seizures and falls. The 
enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not 
support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be 
met at a lower 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 psychotherapy 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 psychotherapy services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy services.

You asked the Plan to waive the copayment for endoscopy services. You say that this is a covered service and you should not be billed for services that are covered. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $150 per day for outpatient procedures and services, including, but not limited to diagnostic and therapeutic endoscopy and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.

You have been asked to pay $150 for the endoscopy services. The endoscopy services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography services (76642, 77066, G0279).

You asked the Plan to pay for the mammography services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 76642, 77066, & G0279 are not supported in the medical record. Specifically, the records support 1 unit each of these services. The services have already been paid under a previous claim. This claim is a duplicate. Based on this information, we decided that Medicare rules for coverage of the mammography services have not been met. Therefore, we decided that the Plan does not have to pay for mammography services (76642, 77066, G0279).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 
6, 2020. 
 
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your 
request. The Plan says that there were no medical records showing that the prescribing physician ever saw the 
member. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis 
provided to the enrollee on August 6, 2020.