Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 18, 2021 to January 26, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically necessary and reasonable. The Plan denied your request. The Plan says that the enrollee did not require acute care admission and could have been managed at an observation level.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that this enrollee was brought to the emergency department by ambulance on January 18, 2021. They were evaluated and admitted, and once their condition was stabilized and improved they were discharged home on January 26, 2021. The record shows 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 18, 2021 to January 26, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not check glucose levels four or more times per day and does not inject insulin three or more times per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal home helper.

You asked the Plan to pre-approve the home helper services. You say that you took your papers to the doctor. You also say that your doctor advised that they never received papers from your insurance company. The Plan denied your request. The Plan says you do not meet the criteria for the requested benefit.

Medicare generally does not cover personal home helper services. However, the Plan offers an extra 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. Based on this information, we decided that the rules for coverage of the personal home helper services have not been met. Specifically, the record shows that the Plan requested medical records from the provider, but none were received. The record also shows that the Plan made multiple attempts to contact you to advise that a Release of Information form needed to be submitted to your provider in order for medical records to be released. Therefore, we decided that the Plan does not have to pre-approve a personal home helper.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two clinical crown lengthenings (D4249 x2).
You asked the Plan to pre-approve the clinical crown lengthenings. You say that a patch is not a standard of care. You also say that crown lengthenings need to be provided to allow for supra gingival margin lines. The Plan denied your request. The Plan says this service is not covered under the enrollee's plan.
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 two clinical crown lengthenings (D4249 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided March 13, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 80307, & G0483 are not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service described in the records (11, office setting). 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 lab services (80307, G0483) provided March 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided to the enrollee on September 8, 2020.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says codes 99601 and 99602 have a status code of "I," which means these codes are not used for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an issue with the status code indicator and the inability of these codes to be paid by Medicare. The Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on September 8, 2020.
Appeal type: Other
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).

The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
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) received March 31, 2021.

You asked the Plan to pay for the surgical placement of implant body. You say that this service was medically necessary and was not cosmetic. The Plan denied your request. The Plan says the requested service is 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 surgical placement of implant body: endosteal implant (D6010) received March 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the indomethacin, 50 mg, (A9270-GY) provided on
December 15, 2020.
You asked the Plan to pay for the self-administered drug. You say that you were not aware that this was not a
covered service. You say that this has always been done in your other surgeries in the past. You also say that
have not been any problems in the past. The Plan denied your request. The Plan says the drug that you received
is considered self-administered.
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan
also says the drug you received is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the indomethacin, 50 mg,
(A9270-GY) provided on December 15, 2020.
Benefits for the self-administered drug 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 the laboratory services rendered on June 5, 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 services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 12, 2021.

You asked the Plan to pay for the limited oral evaluation (D0140). You say that you paid $67 for the oral exam and want to know why the service was denied. The Plan denied your request. The Plan says the claim was correctly denied due to exceeding the frequency maximum of one procedure per plan year.

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, a limited oral evaluation is only covered once per plan year. The Plan paid for a limited oral evaluation provided on February 12, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 13, 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 claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 5, 2021.

You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on August 28, 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 procedure code 01926 is 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 01926 is anesthesia for therapeutic interventional radiological procedures involving the arterial system; intracranial, intracardiac, or aortic. 

We find that CPT code 01926 is not supported in the medical record. Specifically, there is no documentation of start and stop time for the anesthesia services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99337) provided on February 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a rest home visit. You say that this was a medically necessary service provided in good faith. The Plan denied your request. The Plan says this was not authorized.

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 rest home visit (99337) provided on February 23, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy evaluation provided on
December 14, 2020.

You asked the Plan to waive the copayment for the physical therapy evaluation. You say that you were told
your copayment for outpatient surgery would be $295. You say that you paid the copayment and should not
owe an additional $35 if you were quoted $295. The Plan denied your request. The Plan says the copayment
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 $35
copayment for each Medicare-covered physical therapy and speech-language therapy visit.

You have been asked to pay a $35 copayment for the physical therapy evaluation. The physical therapy
evaluation falls within the "Outpatient Rehabilitation Services" benefit category. Outpatient therapy is
considered a separate service that is not included in the surgical benefit. 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 physical therapy evaluation provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a basket for a walker.
You asked the Plan to pre-approve the basket. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a basket for a walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a male external catheter (A4349).
You asked the Plan to pre-approve the catheter. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor's notes do not show permanent incontinence.
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 catheter. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not confirm the presence of permanent urinary incontinence. The records do not indicate whether the condom catheter is to be used as an alternative to an indwelling catheter. As such, this is 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 catheter have not been met. Therefore, we decided that the Plan does not have to pre-approve a male external catheter (A4349).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided on January 19, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Xiidra 5% solution (J3490).
You asked the Plan to pre-approve this medication. You say that this eye solution is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xiidra 5% solution (J3490). Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.