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

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on January 8, 2020.
You asked the Plan to pay for the occlusal guard. You say that when your dentist contacted the Plan last October, he was told that the occlusal guard was covered. You also say that you needed to postpone the creation of an occlusal guard and in that time, the approval had been cancelled. The Plan denied your request. The Plan says this service is 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 occlusal guard (D9944) provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or more power seating system motors (E2311), and power seat elevation system (E2300). You asked the Plan to pre-approve an expandable controller, harness, electronic connection, and power seat elevation system. You say that the requested items 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. 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 an expandable controller, harness, electronic connection, and power seat elevation system. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you are not noted to have an inability to utilize a lesser device (lightweight manual wheelchair). Therefore, this request is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness, electronic connection, and power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), harness for upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or more power seating system motors (E2311), and power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office visit provided to the enrollee on
October 9, 2019.
You asked the Plan to pay for the office visit. You say that the medical records indicate separate specialties.
The Plan denied your request. The Plan says the denied service does not meet the definition of a new patient.
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 99204 is office or other outpatient visit for the evaluation
and management of a new patient.
We looked at the file and the rules. The records show that the enrollee medical services from the same
physician specialty, in the same group practice, within the previous 3 years. Based on this information, we
decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the
Plan does not have to pay for the new patient office visit provided to the enrollee on October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulmonary testing services (94726, 94060) provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON pulmonary testing services. You say that these services should be covered. The Plan denied your request. The Plan says these 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 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 pulmonary testing services (94726, 94060) provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 24, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that it is the facility's responsibility to obtained prior
authorization. The Plan denied your request. The Plan says the member's primary care physician did not refer
these services. The Plan says that no prior 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 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 physician services provided on June 24, 2019 by
an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on December 8, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says the enrollee was under hospice election from November 05, 2019 through January 01, 2020. The Plan states that this claim should be submitted to Original Medicare.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.At the time of service, the enrollee was under hospice election.  Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on December 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on September 16, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that the ordering physician is also out-of-network. The Plan says that no prior 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 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 ophthalmology services provided on September
16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve eustachian tube dilation. We decided that the Plan does not have to
pre-approve a nasal valve repair.
You asked the Plan to pre-approve eustachian tube dilation. You say that the services are necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.
We decided that the Plan has to pre-approve eustachian tube dilation. We asked our physician reviewer to
carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct
in denying the request to pre-approve eustachian tube dilation. Our reviewer says that the requested service is
considered medically reasonable and necessary in this case. Our physician reviewer found for the issue of
bilateral eustachian tube dilation, the enrollee has failed medical management for his eustachian tube
dysfunction. The Academy of Otolaryngology recognizes eustachian tube dilation as a valid treatment option
for eustachian tube dysfunction. They note that the enrollee should have symptoms such as ear fullness or ear
pressure. According to the Academy's guidelines, the enrollee meets criteria for eustachian tube dilation. It is
not considered experimental and is considered medically reasonable.
Therefore, we decided that the Plan has to pre-approve eustachian tube dilation.
We also decided that the Plan does not have to pre-approve a nasal valve repair. Our reviewer says that the
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found the latera implant is a new device. All the literature supporting its use is industry sponsored. There have
not been any randomized controlled trials (RCT) comparing Latera to the current standard of care. Therefore, it
should be considered investigational at this time.
Therefore, we decided that the Plan does not have to pre-approve a nasal valve repair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 24, 2020 to February 11, 2020 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 January 24, 2020 to February 11, 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 intubation services rendered on September 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 31500 is not supported.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 31500 is intubation, endotracheal, emergency procedure.We find that CPT code 31500 is not supported in the medical record. Specifically, there is no documentation that endotrachel intubation for an emergency procedure was performed. 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 intubation services rendered on September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 9, 2019.
You asked the Plan to pay for the dental services. You say that you were required to get dental work completed
as a requirement to have knee replacement surgery. The Plan denied your request. The Plan says that dental
services are not covered by Medicare.
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
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on
September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 22, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM) and supplies.You asked the Plan to pre-approvea CGM and supplies. You say that trying to do a finger stick is difficult because of eye issues.The Plan denied your request. The Plan says that you do not meet Medicare rules for coverage.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or more times a day or testing your blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM) andsupplies
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 3, 2020.
You asked the Plan to pay for the moderate sedation services. 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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT code 99153 is not supported in the medical record. Specifically, the enrollee was inpatient at a hospital facility for this date of service. Therefore, separate payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services provided to the enrollee on September 30, 2019.
You asked the Plan to pay this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you submitted a code with NDC number 49281-0405-88. This is for Fluzone High Dose Influenza Vaccine. The packaged NDC number is 49281-0405-65 and the unit NDC is 49281-0405-88. Confirmed through the NDC crosswalk CPT code 90662 is in fact for Fluzone High Dose Influenza Vaccine. Per the FDA, "Fluzone High-Dose is indicated for active immunization of persons 65 years of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine." Per the above guidelines we find the Medicare rule for payment of this claim has not been met because the enrollee in this case is less than 65 years old.
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 code 90662 is only covered for enrollees who are 65 years of age and older. The enrollee is not 65 or older. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services and additional critical care services provided to the enrollee on August 17, 2019. You asked the Plan to pay for the services provided. You say that The Plan denied your request. The Plan says the billed services 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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). The file shows that 3 additional units of critical care were billed for the date of service at issue. We find that 3 units CPT code 99292 is not supported in the medical record. The CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that the sedation services required the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services and additional critical care services provided to the enrollee on August 17, 2019.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 the enrollee was medically stable. The enrollee required minimal assistance for bathing and toileting. The enrollee required moderate assistance with upper body dressing and maximum assistance with lower body dressing. The documentation does not support that the enrollee requires supervision by physical medicine and rehabilitation physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not required an intensive therapy program. The enrollee's care needs can be met at a lower 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from October 31, 2019 to November 4, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services whichthe enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. The Plan also says that appropriate care could have been rendered/obtained at a lower level of care, or in the home.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 skilledtherapy 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 forthe skilled nursing services provided from October 31, 2019 to November 4, 2019.