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

We decided that the Plan does not have to pay for the diagnostic casts, comprehensive oral evaluation, complete series of intraoral x-rays, or pay more for the immediate maxillary denture, and immediate mandibular denture provided on October 10, 2019 and October 24, 2019.
You asked the Plan to pay for the diagnostic casts, comprehensive oral evaluation, complete series of intraoral x-rays, or pay more for the immediate maxillary denture, and immediate mandibular denture. You say that your dental problems are a direct result of stage III oral cancer and your medical treatment of chemotherapy and radiation. You also say that your dental issues were preventing you from eating many foods and you have suffered a lot of weight loss. The Plan denied your request. The Plan says you had already received the maximum amount of coverage allowed for this type of service.
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 Plan offers a $750 annual dental benefit maximum. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on October 24, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the diagnostic casts, comprehensive oral evaluation, complete series of intraoral x-rays, or pay more for the immediate maxillary denture, and immediate mandibular denture provided on October 10, 2019 and October 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care rendered on January 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says code 99221 is not separately payable.The Plan must follow Medicare rules. The rules say that post-operative services are included in the global surgical period.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99221 (initial hospital care) within the 90 day global surgical period for surgery billed on January 8, 2020. Payment for code 99221 is included in the global surgicalpayment.Therefore, we decided that the Plan does not have to pay forthe initial hospital care rendered on January 17, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided from January 10, 2020 to January 31, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received SNF care on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copay per day for days 1-20, and a $178 copay per day for days 21-100 for Skilled nursing facility (SNF) care. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received SNF care from the first admission on December 9, 2019 to December 24, 2019 (days 1-15) and the enrollee was charged a $0 cost-share. The file shows that the enrollee had a second admission to SNF from January 10, 2020 to January 31, 2020 (22 days). The enrollee was charged a $0 cost share for days 16-20 (5 days) and a $178 copayment per day for days 21-38 (17 days), totaling $3026. The SNF care falls within the Skilled nursing facility (SNF) care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided from January 10, 2020 to January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-preferred brand blood glucose test strips.
You asked the Plan to pre-approve non-preferred brand blood glucose test strips. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be
provided by a preferred brand.
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 non-preferred blood glucose test strips when there is adequate
information that the use of an alternate brand is medically necessary in your specific situation.
The requested brand of test strips in this case is not a preferred brand with the Plan. The Plan has network
preferred brands available that can provide the items 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 preapprove
non-preferred brand blood glucose test strips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the upper extremity (73221) provided on September 24, 2019.
You asked the Plan to pay for the MRI. You say that services were medically necessary. The Plan denied your request. The Plan says there were network providers available. The services were not emergent or preauthorized.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 Magnetic Resonance Imaging (MRI) of the upper extremity (73221) provided on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 12, 2020.You asked the Plan to pay for the dental service. You say that you have Parkinson's Disease. You also say that you cannot take regular bitewing x-rays.The Plan denied your request. The Plan says the panoramic x-ray is not a covered service.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 panoramic x-ray is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Collagenase injections (J0775) provided on December 17, 2019.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the injections 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $756 coinsurance (20% x $3,780 of the Medicare allowed amount) for the Medicare Part B prescription drug injections 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 waive the coinsurance for the Collagenase injections (J0775) provided on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram report provided on September 29, 2019.
You asked the Plan to pay for the services provided. You say that the interpretation and report directly contributed to the diagnosis and treatment of the enrollee. The Plan denied your request. The Plan says the services do not meet the requirements for the professional component of an EKG.
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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. The documentation provided does not include an interpretation and report for the billed services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram report provided on September 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drugs, two alveoloplasties, and three additional extractions provided on May 3, 2019.
You asked the Plan to pay for the therapeutic parenteral drugs, two alveoloplasties, and three additional extractions. You say that your dentist assured you that your dental insurance would cover these services. You also say that the provider did not get a predetermination for these services. The Plan denied your request. The Plan says therapeutic parenteral drugs and alveoloplasty are not covered benefits. The Plan also says that the benefits for extractions had been satisfied and the frequency limitation had 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, therapeutic parenteral drugs and alveoloplasty are not among those covered under this benefit. The contract says that extractions are limited to two procedures per calendar year. The record shows that you received five extractions on May 3, 2019, two of which were covered by the Plan, and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drugs, two alveoloplasties, and three additional extractions provided on May 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 26, 2019 to July 27, 2019.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says the services could have been provided under observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was admitted to the provider on July 26, 2019 for weakness. Four days prior to admission, the enrollee had a mechanical fall landing on her buttocks. The enrollee was able to ambulate and worked well with PT/OT using a fronted wheeled walker. Her pain was controlled with low dose Norco. She reported feeling well and improved following initial therapy. She was discharged home July 27, 2019 with outpatient follow-up. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 26, 2019 to July 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that you need this device because you check
your glucose frequently. The Plan denied your request. The Plan says you do not meet criteria for this device.
The Plan must follow Medicare rules. Medicare rules say that a CGM is covered if the beneficiary is insulintreated
with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous
insulin infusion (CSII) pump.
We looked at the file and Medicare rules. The medical records do not show that you are treated with three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump.
Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM have not been
met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose
monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional left sacroiliac joint radiofrequency
ablation (RFA) for the enrollee.
You asked the Plan to pre-approve the injection. You say that the right RFA was approved and covered under
the plan. The Plan denied your request. The Plan says there is no high-quality peer-reviewed literature that
supports the efficacy of this treatment for patients with SI-joint mediated pain.
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 injection. Our reviewer says that the
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer
found this procedure is considered experimental and investigational, because of the wide variation in efficacy
reported in the peer-reviewed literature. Therefore, the request is considered not medically 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve an additional left sacroiliac joint radiofrequency ablation (RFA) for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forCPT code 73110 provided on February 9, 2020.You asked the Plan to pay forCPT code 73110. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.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. Specifically, Medicare guidelines state that modifiers LTand RT are to be used to identify procedures, which can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals use the appropriate -RT or -LT modifier to identify which of the paired organs was operated upon. In this case, procedure code 73110 is an x-ray of the wrist, minimum of 3 views, which is not considered to be a paired organ. The Plan has not provided any supporting documentation showing that procedure code 73110 is only payable if billed with modifiers 50, LT, or RT.Therefore, we decided that the Plan has to pay forCPT code 73110 provided on February 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on February 26, 2020.You asked the Plan to waive the copayment forthe services. You say that you should not be getting billed for a routine eye exam because when you contacted the plan you state you were told by member services that an eye exam would a $0 copay.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a medical eye examination on February 26, 2020. This was not a routine eye exam. You are asked to pay a $35 copayment for the medical eye examination. 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 forophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Glucose Monitoring System sensors.
You asked the Plan to pre-approve continuous glucose monitor sensors. You say that because of your condition you have difficulty testing. The Plan denied your request. The Plan says you are not on insulin and do not test three or more times a day.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. You are not on insulin. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve Glucose Monitoring System sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the resin-based composite and maxillary partial denture.
You asked the Plan to pre-approve the resin-based composite and maxillary partial denture. The Plan denied
your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
resin-based composite and maxillary partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the patient needs this care to regain
strength. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically
necessary. The enrollee is receiving appropriate care at the current acute care facility. As acute care hospitals
(ACH) and LTACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee from the current ACH to an LTACH.
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 that the patient is currently undergoing treatment at an ACH for pneumonia. The
enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care
for any ongoing long term care needs.
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 1 power operated vehicle and accessories.You asked the Plan to pre-approvea Group 1 power operated vehicle and accessories. You say that you need a scooter to be more mobile around the community and be safe. The Plan denied your request. The Plan says the documentation shows you are able to self-propel a manual wheelchair in the home and can use a cane to independently ambulate.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. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 1 power operated vehicle and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hygienic air system.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the requested items are not covered.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Medicare will not pay for equipment used for comfort or for convenience. Therefore, we decided that the Plan does not have to pre-approve the hygienic air system.