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

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home use (D9630), gingival irrigation - per quadrant (D4921), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381).

You asked the Plan to pay for the dental services (D9630, D4921, D4381). You say that the requested services were necessary to resolve periodontal disease. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home use (D9630), gingival irrigation - per quadrant (D4921), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you do not use a ventilator mounted to the wheelchair and do not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer and unable to perform a functional weight shift given your level of strength noted in the OT note. There is no detailed treating medical provider neuromuscular exam. The documentation does not clearly reveal a neuromuscular disease to indicate a group 3 power wheelchair. There is no congenital skeletal deformity or myopathy. 

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 a group 3 power wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
November 14, 2019, through December 13, 2019.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services after November 13, 2019 were not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee is an 80-year-old female with hyponatremia and alcoholism. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received PT, ST and OT in the SNF. By the dates in question, the enrollee was at an independent to modified independent level with functional mobility including gait to 300 feet. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from November 14, 2019, through December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 13, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because you were told you would not owe a copayment and you cannot afford the charges. 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 $115 copayment for ultrasounds. 

You have been asked to pay the allowed amount of $99.89, which is less than the $115 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the foot insert provided on December 16,
2020.

You asked the Plan to waive the coinsurance for the foot insert. You say that you were informed the inserts
would have no copayment or coinsurance. You say that you were not prepared to pay so the coinsurance should
be waived. 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-covered prosthetic devices and supplies.

You have been asked to pay $79.94, which is 20% of the allowed amount for the foot insert. The allowed
amount is $399.68 (20% x $399.68 = $79.94). The foot insert falls within the "Prosthetic Devices and Related
Supplies" benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the foot insert provided on
December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5256) provided November 13, 2020.

You asked the Plan to pay for the hearing aids. You say that the hearing aids were necessary due to sudden hearing loss and you would like the Plan to pay at least  of the bill. The Plan denied your request. The Plan says hearing aids are not covered because they were not supplied by a provider in the Plans third-party hearing vendor's network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are supplied by a network provider. 

We looked at the file and the Plan's rules. The provider in this case is not a network provider with the Plan at the time of the service. 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 at issue. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5256) provided November 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 23474, CPT 23430, CPT 23615) provided to the enrollee on November 3, 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 denied codes are not supported by the medical records submitted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of the denied codes is:

CPT 23474: 

Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component 

CPT 23430: 

Anchoring of biceps tendon 

CPT 23615:

Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed 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 operative report documents the enrollee had a previous Hemiarthroplasty, and a reverse total shoulder, therefore, a more appropriate code than CPT 23474 should be reported to support documentation. The operative report does not support the use of modifier 59 (distinct procedural service) for CPT 23430. The documentation should support that the service is distinct and separate from the primary service. CPT 23615 is not supported, due to inappropriate reporting of primary service. When reporting correct primary service, CPT 23615 is included and not separately reported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 23474, CPT 23430, CPT 23615) provided to the enrollee on November 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the interspinous device. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is considered investigational and is not covered.

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 interspinous device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex interspinous device is experimental. More research is needed to show safety and efficacy of the device. 

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 interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve use of Botox (botulinum toxins).

You asked the Plan to pre-approve Botox. You say that the enrollee had a trial of Botox that showed improvement, and you would like 1 more injection. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of Xeomin before it will approve Botox.

The Plan must follow Medicare rules. Medicare rules say that if a health plan decides to adopt and apply step therapy to Part B drugs, the Plan must disclose that Part B drugs may be subject to step therapy requirements in the Plan's Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents. 

We looked at the file and Medicare rules. The Plan's Evidence of Coverage does not clearly disclose that step therapy rules apply to Medicare Part B prescription drugs. The Plan did not submit a copy of the Annual Notice of Change document. The Plan has not provided any reason other than the application of step therapy rules to support a denial of authorization. Based on this information, we decided that Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve use of Botox (botulinum toxins).

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on December 3, 2020.

You asked the Plan to pay for the PET scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

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 PET scan. Our reviewer says that the documentation does not support that the PET scan provided was medically reasonable or necessary. Our physician reviewer found the PET/computerized tomography (CT) showed a response to treatment with decreased in size of the primary site as well as nodal and distant (peritoneal and hepatic). There are no records describing the need for this PET/CT or why it was ordered other than mentioning a comparison to the October 18, 2020 body CT. Therefore, the services provided were not medically 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320) received September 25, 2020 from the opt-out provider.

You asked the Plan to pay for endodontic therapy, premolar tooth. You say that you were referred by your dentist for an emergency. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare.

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. The Plan has submitted evidence that the provider in this case has opted out of Medicare. Per the Plan's contract, you may see any licensed dental provider who accepts Medicare patients in the U.S. and has not opted out of Original Medicare. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320) received September 25, 2020 from the opt-out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay from November 10, 2020, to November 17, 2020.

You asked the Plan to waive the deductible and copayment for an inpatient hospital stay. You say that you feel that the charges are too high. 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. Your contract with the Plan says that there is a $1000 deductible. Your contract with the Plan also clearly says that after the $1,000 deductible has been met, enrollee's must pay a $725 copayment per inpatient stay. 

You had an inpatient hospital stay from November 10, 2020, to November 17, 2020. The record shows that you had only paid $466.40 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $533.60. Now that the $1,000 deductible has been met, you are also responsible to pay the $725 copayment. The total amount you owe is: $1,258.60. 

The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time an inpatient hospital stay was received on November 10, 2020 to November 17, 2020. Therefore, we decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay from November 10, 2020, to November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided October 15, 2020.

You asked the Plan to pay for the Tdap vaccine. You say that your physician recommended that you receive the high does flu shot as well as DPT booster shot. You confirmed with the provider's office that you should receive the vaccine at your doctor's office. The Plan denied your request. The Plan says This is a Part D prescription drug and is not covered under Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided October 15, 2020.

Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing provided on October 14, 2020.

You asked the Plan to pay for genetic testing. You say that this testing may be ordered for patients at an
increased risk of bladder cancer to aid in the diagnosis of new or recurrent bladder cancer. The Plan denied
your request. The Plan says this test is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that CxBladder test is not covered by Medicare for
date of service October 14, 2020.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for
CxBladder testing provided on October 14, 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 a SNF would be more appropriate, as the enrollee is unable to participate in three hours
of daily 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 surgical treatment of a hip fracture after a fall. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 28, 2020.

You asked the Plan to pay for the ambulance services. You say that you have emotional problems, live alone
and do not drive. 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 November 28, 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 November 28,
2020.