Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinuation of oxygen therapy, for the enrollee.Youasked the Plan to pre-approveoxygen equipment. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the Medicare rules have not been met.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 topre-approve oxygen equipment. Our physician reviewer found coverage criteria for portable supplemental oxygen are not met. The records do not contain any information on oxygenation either at rest or during activity. Therefore, Medicare coverage requirements are not met, and oxygen is considered 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 oxygen equipment have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of oxygen therapy, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) provided on February 3, 2020.You asked the Plan to pay for the cone beam CT capture and interpretation. You say that the provider removed your existing crown, performed a root canal, and replaced the same crown. You also say that the buildup was necessary as part of the routine procedure.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.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 cone beam CT capture and interpretation (D0364) provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Upwalker H200 purchased on October 21, 2019.You asked the Plan to reimburse you forthe walker. You say that the Plan should reimburse you for the walker.The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary foritems provided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not enrolled in Medicare.Therefore, we decided that the Plan does not have to reimburse you forthe Upwalker H200 purchased on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% drops.You asked the Plan to pre-approve Xiidra. You say that the eye drops are medically necessary.The Plan denied your request. The Plan says the drug at issue is not eligible for coverage under the Part B medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Xiidra 5% drops.Benefits for Xiidra may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered miscellaneous item (A9270) sales tax (S9999) purchased January 6, 2020.You asked the Plan to pay for miscellaneous items and sales tax. You say that you were told by the nurse that the Fitbit would be covered by the plan.The Plan denied your request. The Plan says the plan approved reimbursement for the Fitbit in the amount of $79 but the miscellaneous item and sales tax are not covered.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Miscellaneous items and sales tax are not covered by Medicare or the Plan.The Plan's rules for coverage of gym benefits have not been met because the miscellaneous items and sales tax are not covered.Therefore, we decided that the Plan does not have to pay for non-covered miscellaneous item (A9270) sales tax (S9999) purchased January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 6, 2020.You askedthe Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant /abutment supported removable denture for edentulous arch -mandibular (D6111) and complete maxillary denture (D5110) provided on January 24, 2020.You asked the Plan to pay for the mandibular implant /abutment supported removable denture and complete maxillary denture. You say that if the complete maxillary denture process is done correctly, it requires multiple appointments to receive properly fitting dentures. You also say that the implants are required to hold your dentures, which is recommended for all individuals that have Tori growth.The Plan denied your request. The Plan says the implant /abutment supported removable denture for edentulous arch -mandibular is not a covered benefit under your dental plan. The Plan also says that you received a complete maxillary denture less than five years ago.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 implant /abutment supported removable denture for edentulous arch -mandibular (D6111) is not among those covered under this benefit. The contract also clearly states that complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture on June 26, 2019 and your complete maxillary denture (D5110) benefit has been exhausted. The record also shows that the Plan confirmed with the treating provider that there was a signed treatment plan showing that you were aware these services would not be covered by your plan.Therefore, we decided that the Plan does not have to pay for the implant /abutment supported removable denture for edentulous arch -mandibular (D6111) and complete maxillary denture (D5110) provided on January 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on January 22, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for ultrasounds. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 foran ultrasound provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient consultation (99254) provided on June 7, 2019.
You asked the Plan to pay for an inpatient consultation. You say that these services should not require authorization. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 code 99254 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient consultation (99254) provided on June 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle foot orthoses provided on November 22, 2019.You asked the Plan to pay forthe ankle foot orthosis (L1971). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not 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 visitis 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 payforthe ankle foot orthoses provided on November 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted procedure of the nervous system (64999-62) provided on December 16, 2019.You asked the Plan to pay forthe unlisted procedure of the nervous system. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the billed codeis not supported in the medical records provided.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 64999-62is unlisted procedure of the nervous system.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 unlisted procedure of the nervous system. Our reviewer says that your request does not meet criteria for billing or reimbursement consideration. Our physician reviewer found that the medical records provided donot include documentation indicating what procedureperformed December 16th was billed under the unspecified code of 64999-62, therefore this service cannot be verified. According to the National Correct Coding Initiative Policy Manual for Medicare Services, the procedure note must include specific documentation indicating the procedure billed under the unspecified code. Medicare rules state, "For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has 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 unlisted procedure of the nervous systemhave not been met.Therefore, we decided that the Plan does not have to pay for the unlisted procedure of the nervous system(64999-62) provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the extraction (D7140) provided from January 15, 2020 to January 23, 2020.
You asked the Plan to pay for the panoramic x-ray and extraction. You say that one of your teeth broke off while you were eating. You say that the x-rays had to be done. You say that further complications and injury were prevented due to having your tooth extracted. The Plan denied your request. The Plan says the panoramic x-ray is not listed as a covered service. The Plan also says the extraction is not listed as a covered service.
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 panoramic x-ray and extraction are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the extraction (D7140) provided from January 15, 2020 to January 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services rendered from May 7, 2019 to May 9, 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 the enrollee exceeded the benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNFin each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from November 19, 2018 to May 7, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services rendered from May 7, 2019 to May 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does nothave to waive the copayments forthe cardiac rehabilitation visits provided from November 18, 2019 to December 23, 2019.You asked the Plan to waive the copayments forthe cardiac rehabilitation visits. You say that you did not know that there was a $30 copayment for each visit. You say this is a lot of money. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each in-network Medicare-covered visit. You have been asked to pay a $30 copayment for each of the cardiac rehabilitation visits. The cardiac rehabilitation visits fall within the "Cardiac rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe cardiac rehabilitation visits provided from November 18, 2019 to December 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 71045) provided on January 4, 2020.You asked the Plan to pay for CPT 71045. The Plan denied your request. The Plan says this is a column two code.The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part of an edit pair with procedure code 32555. Procedure code 32555 is a column one code, and procedure code 71045 is a column two code. Procedure code 32555 has also been billed for this date of service, which means that procedure code 71045 is not eligible for payment.Therefore, we decided that the Plan does not have to pay for the services (CPT 71045) provided on January 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing exam provided on January 27, 2020.You asked the Plan to waive the copayment for the hearing exam. The Plan denied your request. The Plan says that the correct cost sharing was 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 $45 copayment for Medicare-covered diagnostic hearing exams. You have been asked to pay a $45 copayment for the hearing exam. The hearing exam falls within the Medicare-covered diagnostic hearing exams benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the hearing exam provided on January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the enrollee has already been in the hospital for 29 days and is ready for transfer to the next level of care.The Plan denied your request. The Plan says the enrollee's current needs are being met in the acute setting. The Plan says that the LTACH would add no additional services.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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for severe gallstone pancreatitis, requiring surgery and drains. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee continues to require wound care, drain care and supplemental nutrition. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 long term acute care hospital (LTACH) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe catheters and lubricant provided on February 24, 2020.You asked the Plan towaive the coinsurance forthe catheters and lubricant. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance for the catheters and lubricant. he catheters and lubricant falls within the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe catheters and lubricant provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 9, 2020.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on December 19, 2019by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the services are an extension of the initial visit.The Plan denied your request. The Plan says there is no network deficiency for the services, andalternate network providers were found.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 OON services.Therefore, we decided that the Plan does not have to pay forthe lab services provided on December 19, 2019 by an out of network (OON) provider.