Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO L0650) provided on October
12, 2020.
You asked the Plan to pay for LSO. You say that you are appealing with supporting records. The Plan denied
your request. The Plan says the denial of payment for this item is correct, because the documentation submitted
did not sufficiently document the medical necessity for this item nor did it indicate the provider discussed the
need for this item.
The Plan must follow Medicare rules. Medicare rules say that providers must meet certain specific
documentation requirements for coverage of LSO L0650.
We looked at the file and Medicare rules. The documentation submitted does not include medical record
information describing the medical necessity of this item. The Plan required this information which was not
submitted to them. Without the medical record information for the specific item billed, the documentation
requirements for coverage have not been met.
Based on this information, we decided that Medicare rules for coverage of LSO have not been met. Therefore,
we decided that the Plan does not have to pay for a lumbar-sacral orthosis (LSO L0650) provided on October
12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 11, 2020 and November 18, 2020.

You asked the Plan to pay for the office visits. You say that your original coverage should have been continued until the new policy took effect and the services were all paid for. The Plan denied your request. The Plan says out-of-network services are not covered.

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 by an out-of-network provider on November 11, 2020 and November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from April 18, 2018, through
May 9, 2018, with the reported secondary diagnosis A41.9, Sepsis, unspecified organism.
You asked the Plan to pay for the inpatient services provided from April 18, 2018, through May 9, 2018 with
the reported secondary diagnosis A41.9, Sepsis, unspecified organism. The Plan denied your request. The Plan
says there was insufficient objective clinical evidence to validate the diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with the secondary diagnosis A41.9, Sepsis, unspecified
organism. 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 inpatient services provided from
April 18, 2018, through May 9, 2018 with the reported secondary diagnosis A41.9, Sepsis, unspecified
organism. Our reviewer says that the documentation does not support that the inpatient care is payable as
billed. Our physician reviewer found that the enrollee underwent cholecystectomy three weeks prior and was
readmitted with air containing abscess and concern for colocutaneous fistula. At the time of admission, the
enrollee was febrile and had an elevated white blood cell count with an intrabdominal abscess. The medical
record does not indicate organ dysfunction. The physician assessments do not indicate the presence of
sepsis. The elements of the criteria for secondary diagnosis of A41.9 are not satisfied. The requested DRG 856
cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient services provided from April 18, 2018, through May 9, 2018, with the reported secondary
diagnosis A41.9, Sepsis, unspecified organism.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 19, 2020.
You asked the Plan to pay for the office visit. You say that a provider shouldn't limit access to medically necessary services based on the patient's enrollment in a service plan. You say that the denial should be overturned, and the claim should be processed as in-network. The Plan denied your request. The Plan says prior authorization was required but 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 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 by an out-of-network provider on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 31,
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes
will be considered part of the same panel
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 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
enrollee had molecular pharmacogenetic testing on August 31, 2020. The denial remains upheld as non-covered
as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural
service, so one CPT code must be submitted for the panel.
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 pay for laboratory services provided to the enrollee on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wrist hand finger orthosis (L3807) provided on November 10, 2020.
You asked the Plan to waive the coinsurance for the wrist hand finger orthosis. You say that you feel you 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 you received durable medical equipment on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a wrist hand finger orthosis on November 10, 2020. You have been asked to pay a 20% coinsurance for the wrist hand finger orthosis, totaling $44.50. The wrist hand finger orthosis falls within the Durable medical equipment 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 wrist hand finger orthosis (L3807) provided on November 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued direct skilled nursing services of a RN (G0299).
You asked the Plan to pre-approve the continued direct skilled nursing services of a RN. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says the continued services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued direct skilled nursing services of a RN. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services to provide treatment that is medically necessary. Our reviewer found that you do not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. Our physician reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.
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 continued direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve continued direct skilled nursing services of a RN (G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on November 11, 2020 by an out of network (OON) provider.
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 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 wound care services provided on November 11, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric care provided from July 11, 2020, to July 21, 2020.

You asked the Plan to pay for inpatient psychiatric care. You say that the enrollee remained symptomatic, posed a danger to himself, and required medication adjustment. The Plan denied your request. The Plan says the denial of payment for inpatient level of care is correct, because the enrollee could have been treated in a different level of care such as an outpatient program and prior authorization was not obtained.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric care. Our reviewer says that this inpatient care does not meet the Medicare criteria for payment. Our physician reviewer found based upon the records provided, it was not expected that this enrollee would improve in a reasonable period of time as of July 11, 2020 as he was not showing any dangerousness to self or others, no auditory or visual hallucinations, and no aggressive behaviors.

The enrollee was compliant with treatment and having no side effects to the medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the inpatient level of care rather than a lower level of care for July 11, 2020 and beyond. The Plan's denial of continued inpatient psychiatric care appears appropriate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric care provided from July 11, 2020, to July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010 x 2), semi-precision attachment abutments (D6052 x 2), implant supported retainer (D6075 x 2), and pontics (D6245 x 4).
You asked the Plan to pre-approve the dental services. You say that you feel partials are not suitable. You also say that you want permanent dentures. The Plan denied your request. The Plan says the provided documentation does not show there is a medical condition that would be alleviated by implants or could not be corrected by other covered functional alternatives for prosthetic replacement. The Plan also says that the requested bridge is not covered because the submitted narrative fails to indicate or support any specific physical or psychological condition that preclude the use of a removable prosthesis.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the provided documentation indicates that the old bridge for teeth # 22 to # 27 was failing due to the condition of the abutment teeth. The reviewer found that the Plan provisions state that the most cost-effective treatment must be considered. The reviewer found that the replacement of the teeth is possible with alternative methods at a lower cost. Given the Plan limitations as to providing treatment that is most cost effective, the requested treatment of implants and implant bridge are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve implants (D6010 x 2), semi-precision attachment abutments (D6052 x 2), implant supported retainer (D6075 x 2), and pontics (D6245 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you would like to appeal this service. The Plan denied your request. The Plan says the requested lower partial denture would not be considered an essential service based on policy guidelines and Plan benefit coverage.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the mandibular partial denture when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mandibular partial denture. Our reviewer says that due to the number of teeth that will be in function, the request for a partial lower denture cannot be found to meet criteria and is not medically necessary. Our physician reviewer found you have tooth #'s 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 31 present. You wear an opposing prosthesis. Our reviewer found that with all teeth in contact, there would be contact on tooth #'s 2/31, 4/29, 5/28, 12/21, 13/20 and 15/17 (due to tilt). Our physician reviewer also found that in this case there would be more than eight posterior teeth in contact with the opposing prosthesis in place.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on November 25, 2020.
You asked the Plan to pay for the home visit. You say that the doctor depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the doctor should not be penalized and payment for the claim should be considered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 requested provider in this case is not a network provider with the Plan. 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 home visit provided by an out-of-network provider on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81291, 81479) provided on December 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON genetic testing. You say that this was medically necessary. 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 genetic testing (81291, 81479) provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 8, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on January 5, 2021.
You asked the Plan to waive the copayment for an EGD. You say 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $100 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgery services received from a non-preferred provider on September 15, 2020.
You asked the Plan to waive the copayment for surgery services. You say that no one told you that the provider was non-preferred. The Plan denied your request. The Plan says the correct copayment was applied.
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 $440 copayment for each visit for outpatient procedures and services performed in a non-preferred outpatient hospital or ambulatory surgical center. You have been asked to pay a $440 copayment for surgery services received from a non-preferred provider. Surgery services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 surgery services received from a non-preferred provider on September 15, 2020.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from representatives of the provider or the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.