Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 3, 2019 to September 9, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 3, 2019 to September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 30,
2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says
there is no valid referral for this service
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 a domiciliary, rest home visit provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 5mg milrinone lactate injections (J2260) provided on
October 24, 2019 through October 30, 2019.
You asked the Plan to pay for the milrinone lactate injections. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did
not support that 13 units of injection, milrinone lactate, 5 mg was wasted on the billed date of service.
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 coder 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 milrinone lactate injections. Our reviewer says that CPT
code J2260x13 does not meet criteria for billing or reimbursement consideration. Our reviewer found the
medical records provided do not include documentation to support that 13 units of J2260 JW - Injection,
milrinone lactate, 5 mg was wasted on service dates October 24, 2019 through October 30, 2019, therefore this
service cannot be verified.
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 milrinone lactate injections have not been met. Therefore, we decided that
the Plan does not have to pay for 5mg milrinone lactate injections (J2260) provided on October 24, 2019
through October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device for the enrollee for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the enrollee's health problem.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device for the enrollee for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.
You asked the Plan to pre-approve the implants. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation received fails to indicate that dental implants are medically necessary, or 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 implants 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 implants. Our reviewer says that the requested implants are not medically reasonable or necessary. Our physician reviewer found the documentation provided did not address the treatment plan recommended as to type of prosthesis/prostheses or type of implants to be used. There was no indication that a conventional prosthesis/prostheses could be used. The EOC did not indicate that implants are a covered service. 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 implants have not been met. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anabolic steroids coded 80327 provided on October 18, 2018.
You asked the Plan to pay for the anabolic steroids. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 80327 is anabolic steroids; 1 or 2. We find that CPT code 80327 is not supported in the medical record. Specifically, code 80327 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the anabolic steroids have not been met. Therefore, we decided that the Plan does not have to pay for the anabolic steroids coded 80327 provided on October 18, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 15, 2019 by a non-network provider.
You asked the Plan to pay for these services. You say that you moved and the receptionist said they accepted your insurance. The Plan denied your request. The Plan says the services were rendered by a non-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 has network providers available who can provide 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 medical services provided on October 15, 2019 by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, resin-based composite, and panoramic x-ray provided by an out-of-network provider on January 17, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, resin-based composite, and panoramic x-ray. You say that prior to receiving these services, you looked on the Plan's website to obtain a list of in-network providers in your area. You also say that this dentist was listed as an in-network provider. The Plan denied your request. The Plan says you received non-emergency services from an out-of-network provider.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, resin-based composite, and panoramic x-ray provided by an out-of-network provider on January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 26, 2019 to December 14, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 26, 2019 to December 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 21, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 11, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 service 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 laboratory services provided on December 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for out of network outpatient mental care to the in-network rate. 
 
You asked the Plan to reduce this cost share to the in-network rate. You say that you could not get adequate service in network. The Plan denied your request. The Plan says the contract is clear that if you use out of network providers without prior authorization your cost share could be higher. 
 
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 $55 copayment for out of network outpatient mental health care. 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 reduce the cost share for out of network outpatient mental care to the in-network rate.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided on January 29, 2020. 
 
You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate claim. 
 
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 73030 is radiologic examination, shoulder; complete, minimum of 2 views. 
 
We find that CPT code 73030 is not supported in the medical record. Specifically, the submitted documentation supports one unit of each 73030-LT and 73030-LT were performed. These were already approved and paid by the plan. There is no additional documentation supporting additional studies were performed. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray provided on January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foam filled drive wheel tires provided on July 1, 2019. 
 
You asked the Plan to pay for the foam filled drive wheel tires. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.  
 
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and an itemized shipping/billing invoice from the billing provider to indicate the billed date of service for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the foam filled drive wheel tires provided on July 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on December 18, 2019. 
 
You asked the Plan to waive the copayment for lab work. You say that the lab work should be part of your wellness colonoscopy. The Plan denied your request. The Plan says the correct copayment 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 copayment for outpatient diagnostic tests/laboratory tests/tier 2.  
 
You have been asked to pay a $20 copayment for lab work. Lab work falls within the outpatient diagnostic tests/laboratory tests/tier 2 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 lab work provided by a participating provideron December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism of the seat lift chair purchased on September 5, 2019. 
 
You asked the Plan to reimburse you for the seat lift mechanism of the seat lift chair. You say that you were told you would be reimbursed 100%. The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare after you were given the name of a certified provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment.  
 
The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism of the seat lift chair purchased on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided by an out-of-network dentist on December 17, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you have been seeing this dentist for approximately 20 years. You also say that you asked the Plan before enrolling in this coverage and they told you that this provider would accept this plan. The Plan denied your request. The Plan says the treating provider is not a participating plan provider. The Plan also says that you self-referred to an out-of-network provider for non-emergency services.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided by an out-of-network dentist on December 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures (97112) provided on December 9, 2019 through December 19, 2019. 
 
You asked the Plan to pay for the therapeutic procedures. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says the record does not support the number of units 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 asked our coder 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 therapeutic procedures. Our reviewer says that CPT code 97112 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient information to corroborate that 3 units of CPT 97112 was performed on the billed dates of 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 therapeutic procedures have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedures (97112) provided on December 9, 2019 through December 19, 2019.