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

We decided that the Plan does not have to pay for a complete upper denture (D5110) provided on March 24, 2021.

You asked the Plan to pay for a complete upper denture. You say that the service at issue should be a covered benefit. The Plan denied your request. The Plan says the service at issue is not a covered 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 a complete upper denture (D5110) provided on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns - resin with high noble metal (D6720) and pontic - porcelain fused to high noble metal (D6240) provided November 16, 2020.

You asked the Plan to pay for the retainer crowns and pontic. You say that when you signed up you were told you could see any dentist. The Plan denied your request. The Plan says this service is not covered because the provider 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. The Plan covers the retainer crowns and pontic when you see any licensed dental provider who accepts Medicare patients in the United States 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 retainer crowns and pontic have not been met. Therefore, we decided that the Plan does not have to pay for the retainer crowns - resin with high noble metal (D6720) and pontic - porcelain fused to high noble metal (D6240) provided November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on October 12, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the OON provider on December 15, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the OON provider on December 15, 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 you need inpatient rehabilitation services. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met, and your ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6240).

You asked the Plan to pre-approve the pontic. The Plan denied your request. The Plan says this service is not a covered 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 pre-approve the pontic (D6240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission and post-stabilization care provided from October 10, 2020, to October 14, 2020.

You asked the Plan to pay for the inpatient admission and post-stabilization care. You say that your medical bills are due in full, plus interest. The Plan denied your request. The Plan says the enrollee was stabilized on inpatient admission and should have been considered for transfer to an approved facility.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 admission and post-stabilization care. Our reviewer says that the inpatient admission and post-stabilization care was not medically reasonable and necessary Our physician reviewer found the record indicates that the enrollee presented to the emergency room on October 10, 2020 and was found to have urosepsis. The enrollee also tested positive for the Coronavirus but did not have any sequelae. Our reviewer found that the enrollee continued to be tachycardic and febrile until after antibiotics were changed on October 11, 2021. The white blood cell count which was 18,000 on admission also decreased after the antibiotic change and the mental status approached baseline. The treating physician did not document when the enrollee would have been stable for discharge. Our physician reviewer also found that the enrollee was stable for transfer the morning of October 12, 2020. 

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 inpatient admission and post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient admission and post-stabilization care provided from October 10, 2020, to October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the myocardial perfusion imaging, Tc99m tetrofosmin and regadenoson injection provided on February 15, 2021.

You asked the Plan to waive the cost for the myocardial perfusion imaging, Tc99m tetrofosmin and regadenoson injection. You say that you don't believe the claim was processed correctly per your benefits. The Plan denied your request. The Plan says the cost share 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 $75 copayment per procedure for diagnostic radiology and 20% coinsurance for medical supplies. 20% of the cost for each Medicare-covered Part B drug.

You have been asked to pay a total of $166.94 for the myocardial perfusion imaging, Tc99m tetrofosmin and regadenoson injection.

Service
Allowed Amount
Standard Cost
Member Liability

Myocardial Perfusion Imaging
$548.69
$75
$75

Tc99m Tetrofosmin
$222.20
20%
$44.44

Regadenoson Injection
$237.48
20%
$47.50

TOTAL:
$166.94

The myocardial perfusion imaging and Tc99m tetrofosmin fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The regadenoson 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 cost for the myocardial perfusion imaging, Tc99m tetrofosmin and regadenoson injection provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on February 22, 2021.

You asked the Plan to pay for the dental services. You say that a plan representative gave you 2 phone numbers for in network providers. You say that you called one and set up an appointment to get dentures. You say that you did not know at the time of the appointment that only certain providers at this location were in network. You also say that had you known, you could have made a different choice. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that you were given the names of 2 specific in network providers. The Plan also says that none of the names given were the provider in this case.

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 and complete dentures are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on February 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 16, 2020.

You asked the Plan to pay for therapeutic exercises. The Plan denied your request. The Plan says the Plan has insufficient documentation to corroborate the services to confirm that Medicare coverage has been met.

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 (97110) provided on August 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 24, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that you were not satisfied with the services you received and you do not want to pay the charges. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met.

Specifically, the record shows that you had exceeded the frequency limit prior to this service on February 16, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says you do not have an open wound.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the rebase complete mandibular denture (D5711) received March 1, 2021.

You asked the Plan to pay for the rebase complete mandibular denture. You say that the requested service is necessary. 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 rebase complete mandibular denture (D5711) received March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on March 31, 2021.

You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that you don't understand why the service is not covered. The Plan denied your request. The Plan says the service at issue is not a covered 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 an
adjunctive pre-diagnostic test (D0431) provided on March 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (CPT 99220) provided to the enrollee on November 29, 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 billed diagnosis code does not describe a symptom or condition and is not specific to the reason for the visit.
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 99220 is "Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified healthcare professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity. Typically 70 minutes are spent at the bedside and on the patient's hospital floor or unit."
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 billed diagnosis of homelessness is not a valid primary diagnosis for this service. 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 emergency room services (CPT 99220) provided to the enrollee on November 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 IRF services, and their needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 abutment supported retainers for a fixed partial denture (D6068) and 3 pontics (D6245).

You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The Plan denied your request. The Plan says abutment supported retainers are not listed as covered services. The Plan says that pontics are not listed as covered services either.

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 6 abutment supported retainers for a fixed partial denture (D6068) and 3 pontics (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed provided March 23, 2021.

You asked the Plan to pay for the total electric hospital bed. You say that this bed is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says coverage is not available for a total
electric hospital bed.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital
bed provided March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81240, 812225, 81226, and
81241 provided on January 26, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as 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 81240, 812225, 81226, and 81241 are not supported in the medical record.
Specifically, the services provided were inappropriately billed. The services rendered should be billed with
code 81479 with one unit of service. If a laboratory procedure produces multiple reportable test results, only a
single HCPCS/CPT code shall be reported for the procedure. Based on this information, we decided that
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the laboratory services coded 81240, 812225, 81226, and 81241 provided on January 26, 2021.