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

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 4, 2019. You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the enrollee's insurance clearly states they have dental insurance. You also say that the enrollee has been seeing this provider for a number of years. The Plan denied your request. The Plan says the enrollee's coverage was not in effect on the date these services were provided. Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. The Plan confirmed that the enrollee did not contact the Plan prior to receiving services to verify coverage. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on January 29, 2020.
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 you by an out-of-network provider on
January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit for a compression sleeve fitting (99203).
You asked the Plan to pre-approve the fitting. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria for the compression sleeves is not met, so the fitting is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that compression sleeves are not covered for the treatment of lymphedema in the absence of ulcers. 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 fitting. Our reviewer says that the fitting is not medically necessary. Our physician reviewer found the record does not show any ulcers present. Since there are no ulcers coverage criteria has not been met. 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 fitting have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit for a compression sleeve fitting (99203).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the breast
rendered on December 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 77049 is not covered.
The Plan must follow Medicare rules. The rules say that the OPPS status indicator identifies whether the
service described by the HCPCS code is paid under the OPPS
We looked at the file and Medicare rules. The provider billed procedure code 77049. This code has an OPPS
status indicator of B and is not payable. Based on this information, we decided that Medicare rules for coverage
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic
resonance imaging (MRI) of the breast rendered on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap (15734) provided on September 6, 2019.
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed 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. In this case, the CPT Code Manual definition of code 15734x2 is muscle, myocutaneous, or fasciocutaneous flap; trunk. 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 muscle, myocutaneous, or fasciocutaneous flap. Our reviewer says that CPT code 15734 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation describing a Muscle, myocutaneous, or fasciocutaneous flap; trunk being performed on September 6, 2019, therefore this procedure 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 muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, we decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap (15734) provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive visit (D9998) and adjunctive procedure (D9999) provided on January 8, 2019.
You asked the Plan to pay for the preventive visit and adjunctive procedure. You say that you expect reimbursement for the preventive services. The Plan denied your request. The Plan says your plan does not cover these procedures.
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 preventive visit (D9998) and adjunctive procedure (D9999) provided on January 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the reclining armchair (E1399). 
 
You asked the Plan to pre-approve the reclining armchair. You say that you need this reclining chair to be able to stand up. You have had many falls and suffer from severe pain in the hips and ribs. You also confirmed with Original Medicare that this is covered. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the reclining armchair (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on February 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that the service you received is considered oral surgery or a surgical extraction. You also say that this type of surgery is a contract benefit. The Plan denied your request. The Plan says the bone replacement graft for ridge preservation is a service that is specifically excluded from 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. 
 
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. The Evidence of Coverage specifically lists this service as not a covered service. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided by on January 20, 2020. You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee received a lumbar-sacral orthosis (L0650) from a different provider in 2017. The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee had lumbar-sacral orthosis (L0650) at the time the lumbar-sacral orthosis (L0650) was received. This lumbar-sacral orthosis (L0650) serves the same purpose as the lumbar-sacral orthosis at issue. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthosis at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on January 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face down positioning table (E1399) provided October 2, 2019.
You asked the Plan to pay for face down positioning table. You say that you checked with the plan prior to having surgery and was told the service would be covered and the claim was documented by the doctor that it was medically necessary. The Plan denied your request. The Plan says this item is a precautionary item that can be used for purposes other than the treatment of an illness or injury and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for face down positioning table (E1399) provided October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the current acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an IRF, SNF, sub-acute rehab facility, or home with home health services.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided from September 7, 2019 to November 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan indicates that the services were billed incorrectly and a corrected claim is needed. However, the plan has not submitted documentation showing exactly what was billed incorrectly on the claim. Without supporting documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided from September 7, 2019 to November 5, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses and the lumbar-sacral orthosis provided on October 3, 2019. You asked the Plan to pay for the ankle foot orthoses (L1971) and the lumbar-sacral orthosis (L0650). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses and the lumbar-sacral orthosis provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle control orthosis provided on December 23, 2019 by an out of network provider.You asked the Plan to pay for the ankle control orthosis (L4350). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says you did not have 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 ankle control orthosis provided on December 23, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visits provided from October 8, 2019 through January 13, 2020. You asked the Plan to waive the cost share for the office visits. You say that you were not aware of the cost. You say that these are a financial burden. 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. Your contract with the Plan says that your deductible is $975. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible. Your contract with the Plan says that you must pay 30% coinsurance for provider and professional services at an out-of-network PCP's office. The item or service you asked the Plan to waive the cost share for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $975 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visits were received on October 8, 2019, November 8, 2019, November 18, 2019 and January 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for these office visits. Since your $975 deductible was met in 2019, you have also been asked to pay $30.86, which is 30% of the allowed amount for the office visit provided on December 6, 2019. The allowed amount is $102.88 (30% x $102.88 = $30.86). The records show that the provider is out-of-network. 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 office visit provided on December 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery services provided on October 18, 2019. You asked the Plan to waive the cost share for the services provided. You say that you did not have surgery. The Plan denied your request. The Plan says you are responsible for the deductible 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 after you pay your $1000 deductible, you pay a $250 copay for outpatient surgery. The file shows that you received a diagnostic sigmoidoscopy. This is a surgical procedure. You have been asked to pay $874 for the services provided. At the time of service, you had not met your $1000 deductible amount. The services fall within the outpatient surgery benefit category. 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 share for the outpatient surgery services provided on October 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 23, 2020. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records (signed by the ordering physician) stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 23, 2020.