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

We decided that the Plan does not have to pay for the two maxillary periodontal medicament carriers with peripheral seals (D5995 x2) and two mandibular periodontal medicament carriers with peripheral seals (D5996) provided on March 12, 2021.
You asked the Plan to pay for the maxillary and mandibular periodontal medicament carriers. You say that you took out dental insurance in good faith and would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your dental 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 pay for the two maxillary periodontal medicament carriers with peripheral seals (D5995 x2) and two mandibular periodontal medicament carriers with peripheral seals (D5996) provided on March 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on February 9, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were told that your injections would be fully covered by your new Plan. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on February 9, 2021. The total allowed amount is $1,207.20 and 20% of that is $241.44.
You have been asked to pay the total coinsurance amount of $241.44 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on February 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair van mileage (S0209) and non-emergency wheelchair van transportation (A0130) provided on January 30, 2021.

You asked the Plan to pay for the wheelchair van mileage and non-emergency wheelchair van transportation. You say that this transportation bill should be covered. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the wheelchair van mileage (S0209) and non-emergency wheelchair van transportation (A0130) provided on January 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 11, 2021, by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that the Plan information states you have a $0 copay for exams, cleanings, x-rays, and fluoride, and are covered in-network and OON. You also say that you used a local dentist and were charged a copay for using an OON provider. The Plan denied your request. The Plan says for services obtained OON the Plan only pays up to a certain amount. The Plan also says that if you choose to see an OON dentist, you might be billed for any amount greater than what the Plan pays.

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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 11, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation services.
You asked the Plan to pre-approve additional trips. You say that you need transportation to get to dialysis. The Plan denied your request. The Plan says your benefit only allows 60 trips for this service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that you have used 60 trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary to handle the enrollee's diabetes. The Plan denied your request. The Plan says the coverage criteria for the device have not been 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.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy evaluation (97165) and wheelchair
management (97542) provided on October 29, 2020.

You asked the Plan to pay for the occupational therapy evaluation and wheelchair management. You say that
the enrollee was not under hospice care. You also say that you feel that this claim was incorrectly denied for
reasons that were unnecessary. The Plan denied your request. The Plan says Original Medicare would be
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal
condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on October 13, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation (97165) and wheelchair management (97542) provided on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to have as much therapy as possible to recover from their accident. You believe this IRF will provide the best outcome. The Plan denied your request. The Plan says while the enrollee does require rehab care, they do not appear to be able to actively participate in the 3 hour/day physical therapy program required for an acute inpatient rehab level of care. A slower physical therapy regimen over a longer period of time seems more appropriate in this case.
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 that 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 does require physical and occupational therapy, but there is no documented need for an intensive
rehabilitation program. 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. Medically necessary
services can be provided in a different level of care.
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 acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on November 16, 2020, to February 17, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with the coinsurance that was applied. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection.
Date of Service
Allowed Amount
Coinsurance
Amount Being Asked to Pay
November 16, 2020
$1,041.15
20%
$208.23
February 17, 2021
$1,360.29
20%
$272.06
Total Amount Being Asked to Pay: $208.23 + $272.06 = $480.29
The correct coinsurance has been applied to the injections that were received. An injection falls within the Medicare Part B prescription drugs 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 an injection provided by a participating provider on November 16, 2020, to February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for neurostimulation treatments provided from January 5, 2021, to March 23, 2021.

You asked the Plan to waive the copayments for neurostimulation treatments. You say that you were not aware that you would owe such a high copayment for the procedure and disagree with the surgery 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You received neurostimulation treatments at an outpatient hospital facility from January 5, 2021, to March 23, 2021, for a total of 5 treatments. Neurostimulation treatments are considered outpatient surgical procedures. Therefore, you are responsible to pay a $300 copayment per each visit. The total amount you owe is: $300 (copayment) x 5 (neurostimulation treatments) = $1,500.

You have been asked to pay the total copayment amount of $1,500 for neurostimulation treatments. Neurostimulation treatments 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 copayments for neurostimulation treatments provided from January 5, 2021, to March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on September 11, 2020.

You asked the Plan to pay for therapeutic exercises. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on September 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 18, 2021.

You asked the Plan to pay for the self-administered drugs. You say that it is reasonable that people would be sent home with an adequate amount of pain relief. The Plan denied your request. The Plan says drugs that are usually self-administered are not covered under Part B of Original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 self-administered drugs provided on February 18, 2021.

Benefits for the self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone graft at time of implant placement (D6104), guided tissue regeneration - resorbable barrier, per site (D4266), and surgical placement of implant body: endosteal implant (D6010) provided March 8, 2021.

You asked the Plan to pay for the deep sedation/general anesthesia, tooth extraction, bone graft, guided tissue regeneration and endosteal implant. You say that you were unaware this provider would not accept Medicare. The Plan denied your request. The Plan says the provider has opted out of Medicare and therefore the services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the deep sedation/general anesthesia, tooth extraction, bone graft, guided tissue regeneration and endosteal implant when provided by a licensed dental provider who accepts Medicare patients in the United States (U.S.) and has not opted out of Original Medicare 

We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the deep sedation/general anesthesia, tooth extraction, bone graft, guided tissue regeneration and endosteal implant have not been met. Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone graft at time of implant placement (D6104), guided tissue regeneration - resorbable barrier, per site (D4266), and surgical placement of implant body: endosteal implant (D6010) provided March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on October 31, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.

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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". 

We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not document that 30-74 minutes of critical care services were provided on the date of service in question. 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 the critical care services (99291) provided on October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on February 9, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that you do not have authorizations ahead of time because your practitioners get a list of patients to see the day they go to the nursing facilities, leaving them no time to secure an authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 domiciliary or rest home visit (99335) provided on February 9, 2021 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 8, 2020.

You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says no authorization was 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve joint injections.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested code is for quality reporting.

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 G0260 is injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography. We find that no payment may be made under the fee schedule for CPT code G0260 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 pre-approve joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services for outpatient cardiac rehabilitation (93797) provided November 16, 2020 to December 30, 2020.

You asked the Plan to waive the copayment for the physician services. You say that you called the Plan before beginning the services to find out what coverage you had and was told there was no charge and then you got billed $5 per visit. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $5 copayment for cardiac rehabilitation services for Cardiac rehabilitation services. 

You have been asked to pay $85 ($5 x 17 days) for the physician services. The physician services fall within the Cardiac rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physician services for outpatient cardiac rehabilitation (93797) provided November 16, 2020 to December 30, 2020.