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

We decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) for tooth #31.
You asked the Plan to pre-approve the crown. You say that your current crown is broken and needs to be replaced. You would like an exception to the frequency limitation. The Plan denied your request. The Plan says one crown per tooth may be covered every five years. The Plan previously paid for a crown on tooth #31 in 2018. Therefore, this service cannot be 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. The Plan can cover one crown procedure per tooth every five plan years Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) for tooth #31.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on January 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that the facility requested that this provider see the enrollee, therefore there is pre-established medical necessity for this visit. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 a practitioner visit provided on January 25, 2021 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283)
provided on January 10, 2021.
You asked the Plan to waive the copayment for the emergency department visit. You say that you would like
reconsideration because you were told this hospital was in-network. The Plan denied your request. The Plan
says you are responsible for a $90 copayment for in-network or out-of-network Medicare-covered emergency
room visits.
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 $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for the emergency department visit. The emergency department
visit falls within the Emergency 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
the emergency department visit (99283) provided on January 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met with a four-wheeled walker with a seat.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found you have a a
personal mobility deficit but the documentation does not support that it impairs participation in MRADLs in
the home. The mobility deficit is able to be helped in the home with a cane.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve an electric wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on December 17, 2020.
You asked the Plan to pay for CGM supplies. You say that the requested items are a necessity for the enrollee. The Plan denied your request. The Plan says rules for CGM supplies have not been met.
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 a valid proof of delivery for the supplies provided in this case. Specifically, the documents submitted as proofs of delivery indicate a need for a signature. No signature appears on the documents. 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 supplies for a therapeutic CGM (K0553) provided on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that you perform drug monitoring in good faith. The Plan denied your request. The Plan says the services 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 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 lab services provided on January 8, 2021 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 direct skilled nursing services of a RN and hospice or
home health care provided on May 18, 2019.

You asked the Plan to pay for the direct skilled nursing services of a RN and hospice or home health care. You
say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan
says the corrected claim was received past 1 year from the original denial date.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the direct skilled nursing services of a RN and hospice or home health care
was not filed until October 5, 2020. This means that more than one calendar year from the date of service had
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the direct skilled
nursing services of a RN and hospice or home health care provided on May 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare for your condition.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648), a knee orthosis (L1851), and a suspension sleeve (L2397) provided on November 12, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis, a knee orthosis, and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 a lumbar-sacral orthosis (L0648), a knee orthosis (L1851), and a suspension sleeve (L2397) provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says LTACHs do not provide clinical advantage over a non LTACH acute care hospitals.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services that are not currently available to the enrollee. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a resin base (D5211) and a partial lower denture with a resin base (D5212).

You asked the Plan to pre-approve the partial dentures. You say that your current dentures are broken beyond repair and need replaced. The Plan denied your request. The Plan says partial dentures may only be covered once within 60 months. You were previously provided with dentures in 2018, which is less than 60 months ago.

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 dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with a resin base (D5211) and a partial lower denture with a resin base (D5212).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for monitored anesthesia (CPT 00811) services provided to the enrollee on September 24, 2020.
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 the claim was incorrectly coded.
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 00811 is "monitored anesthesia for endoscopic procedures, with diagnostic findings." 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. Our coding reviewer found the procedure report documents "69 year old male with a personal history of adenomatous polyps who returns for recall/surveillance colonoscopy." Surveillance colonoscopies are performed on patients who have a prior personal history of colon polys or colon cancer. When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified) with the PT modifier. The procedure began with a diagnostic, and there is a more appropriate code to report in this case. 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 monitored anesthesia (CPT 00811) services provided to the enrollee on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 17, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot L5986 and LK5988.
You asked the Plan to pre-approve a K3 foot. You say that you are writing in regards to an appeal. The enrollee was issued an authorization for partial denial for his prosthetic care. The Plan denied your request. The Plan says the request for a K3 foot does not meet Medicare criteria as reasonable and 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 a K3 foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found L5986 and L5988 do not represent a complete foot. They are parts of a foot that must be paired with a complete foot based on member's functional classification. The vendor indicates that the enrollee expected beneficiary functional level is K3, which is not supported by the medical record provided by the member's nurse practitioner. If these parts are needed, this need must be corroborated by provider without financial interest in the claim outcome, as noted above. There must be clear documentation why this part is needed, which has not been provided. The review has determined that the denied K3 foot does not meet Medicare criteria as reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 foot L5986 and LK5988.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided August 12, 2020.
You asked the Plan to pay for the orthosis. You say that the claim denied for medical records. You have prescription, proof of delivery and clinical. Kindly check the attached documents and reprocess the claim towards appropriate payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met. There is no evidence of an established relationship between the enrollee and the ordering physician and there was no claims submitted for an evaluation and management service.
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 lumbar-sacral orthosis (L0650) provided August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for opioid treatment program (OTP) services received on August 17, 2020.

You asked the Plan to pay for the services. You say that the plan should pay for this, as they did before. The Plan denied your request. The Plan says the provider was not certified according to Medicare guidelines for payment of these services.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 

The rendering provider is not eligible to bill Medicare for these types of services. 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 opioid treatment program (OTP) services received on August 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 17, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 17, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 17, 2020.