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

We decided that the Plan does not have to pay for the services (22899) provided on October 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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 22899 is "Unlisted procedure, spine". 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 use of code 22899 is not supported by the records provided. Our coding reviewer found that the documentation submitted does include documentation of a "Special Report" to confirm the unlisted procedure performed.
CMS requires documentation to support the use of unlisted procedures. 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 the services (22899) provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81230, 81240, 81241, 81291) provided March 9, 2021.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81230, 81240, 81241, 81291) provided March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia infusion to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve Prolia. You say that the enrollee is to resume this treatment with no change, and your previous office visit was covered by the Plan. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a Prolia infusion to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from March 2, 2021, to March 15, 2021.
You asked the Plan to pay for the home visits. You say that these services were approved as a covered benefit under the enrollee's plan prior to being rendered. You also say that you proceeded to provide the treatment with the expectation of being reimbursed. The Plan denied your request. The Plan says the treating provider is not Medicare certified.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from March 2, 2021, to March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).

You asked the Plan to pre-approve the complete maxillary denture. You say that you need a new upper denture because you cannot eat due to your current upper denture not fitting correctly. You also say that your bottom denture will not stay in your mouth because the upper denture helps hold the bottom denture in place. The Plan denied your request. The Plan says this service has exceeded the maximum count allowed per period.

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, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on March 6, 2018 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift chair provided on February 12, 2021.

You asked the Plan to pay for the seat lift chair. You say that you purchased a lift chair rom a local store to reduce costs. The Plan denied your request. The Plan says the provider is not a certified Medicare provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare.

The provider in this case is not eligible to provide services under Original Medicare. The Plan had network providers available who could have provided the lift chair at issue in this appeal. The Plan did not pre-approve the chair at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the seat lift chair provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 26, 2021. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 
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. The file shows that you received dental services from an out-of-
network provider. You were charged 50% of the allowed amount for the services provided. Therefore, we 
decided that the Plan does not have to further pay for the dental services provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 10, 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 September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the enrollee has not had a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to reimburse you for the physical therapy services provided from March 8, 2021, to April 13, 2021.

You asked the Plan to reimburse you for the services provided. You say that you were only supposed to pay a $20 copay per session. The Plan denied your request.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided an explanation for their decision, a denial letter, or any other information as to why reimbursement was not granted. Therefore, we decided that the Plan has to reimburse you for the physical therapy services provided from March 8, 2021, to April 13, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the regadenoson injection provided on March 25, 2021.
You asked the Plan to waive the coinsurance for the regadenoson injection. You say that this was part of the stress test and there should not be a copayment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.
You have been asked to pay $47.97, which is 20% of the allowed amount for the regadenoson injection. The allowed amount is $239.85 ($239.85 x 20% = $47.97). The regadenoson injection falls within the "Medicare Part B prescription drugs" 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 the regadenoson injection provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the critical care, evaluation and management of the critically ill or critically injured patient (99291) provided February 9, 2021, to February 10, 2021.

You asked the Plan to waive the copayment for the outpatient observation hospital stay. You say that the hospital visit was a result of a reaction to the Coronavirus vaccine and you don't believe you should be responsible for the cost. The Plan denied your request. The Plan says the copayment was 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 $200 copayment for outpatient hospital observation services.

You have been asked to pay a $200 copayment for the outpatient observation hospital stay. This service falls
within the Outpatient hospital observation 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 critical care, evaluation and management of the critically ill or critically injured patient (99291)
provided February 9, 2021, to February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee surgery to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the knee surgery. You say that you have been waiting over a year for knee surgery and want to go out-of-network. The Plan denied your request. The Plan says the 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the knee surgery to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the impacted tooth removal for tooth #16 (D7240). 
 
You asked the Plan to pre-approve the impacted tooth removal for tooth #16. The Plan denied your request. 
The Plan says bone removal is not necessary to extract tooth #16. The Plan also says that a less severe 
extraction code could be considered. 
 
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 impacted 
tooth removal for tooth #16 when the services are medically necessary and reasonable. 

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 impacted tooth removal for tooth 
#16. Our physician reviewer says that your dental records and radiographs indicate that tooth #16 appears to be 
fully erupted which does not require a mucoperiosteal flap elevation and bone removal. 
 
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 impacted tooth removal for tooth #16 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the impacted tooth removal for tooth #16 (D7240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skin replacement surgery provided on January 4, 2021.

You asked the Plan to waive the copayment for skin replacement surgery. You say that you are being charged for an office visit but you were there for a procedure, not an office visit. 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 a $35 copayment for specialist services, including surgical services. 

You received skin replacement surgery at a specialists office on January 4, 2021. Because services were provided by a specialist, you are responsible to pay the $35 copayment. 

You have been asked to pay a $35 copayment for skin replacement surgery. Skin replacement surgery falls within the physician/practitioner services, including doctor's office visits 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 skin replacement surgery provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on February 10, 2021.
You asked the Plan to pay for foot orthotics. You say that you need this equipment to walk and heal. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy services provided on March 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for chemotherapy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 chemotherapy services provided on March 23, 2021 by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.

You asked the Plan to pre-approve additional PT. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT visits are not medically necessary per Medicare coverage criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional PT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee is at a functional level that does not require ongoing skilled PT. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) and bone graft at time of implant placement (D6104), or pay more for the surgical extraction (D7210) provided on February 2, 2021.

You asked the Plan to pay for the endosteal implant and bone graft, and to pay more for the surgical extraction. You say that a previous claim was paid for a similar procedure last year. You also say that these services were medically necessary. The Plan denied your request. The Plan says implant services are not a covered benefit, and the bone graft was not covered because you have already received a bone graft. The Plan also says that you are responsible for a 50% coinsurance for extraction services.

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, implants are not among those covered under this benefit. The contract says that bone grafts are covered once per lifetime. The record shows that you received a bone graft on January 3, 2021, and your bone grafts benefit has been exhausted. The contract also says that you are responsible for a 50% coinsurance for extractions. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) and bone graft at time of implant placement (D6104), or pay more for the surgical extraction (D7210) provided on February 2, 2021.