Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional physical therapy visits and 1 additional skilled nursing visit.
You asked the Plan to pre-approve the additional home health visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says seven additional physical therapy and three additional skilled nursing visits have already been approved. Additional services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health visits. Our reviewer says that the additional visits are not medically necessary. Our physician reviewer found the enrollee is walking 200 feet with a rollator walker with stand-by assistance and is stand-by assist to modified independence for transfers and activities of daily living. The seven approved additional visits appear adequate for her needs. The provided records do not document any unstable medical conditions that would require the additional nursing services and the three approved additional visits are adequate.
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 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional physical therapy visits and 1 additional skilled nursing visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 12, 2020 by an out of network (OON) provider.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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 12, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services  are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approveLTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on September 29, 2020.You asked the Plan to pay forthe complete maxillary denture and complete mandibular denture. You say that you were trying to get dentures, but were unable to do so.The Plan denied your request. The Plan says you had exceeded your maximum benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on March 5, 2020,and your annual maximum benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on September 29, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on August 24, 2020.You asked the Plan to pay forthe periodontal maintenance. You say that you are not eligible for a standard cleaning due to having had periodontal surgery.The Plan denied your request. The Plan says this service is not covered by your 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 forthe periodontal maintenance provided on August 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for spirometry provided on May 26, 2020.
You asked the Plan to waive the copayment for spirometry. You say that you feel that you should not owe
anything beyond the $50 copayment you already paid. 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 $20
copayment for outpatient diagnostic procedures and tests.
You have been asked to pay a $20 copayment spirometry. Spirometry 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
for spirometry provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110),
and topical application of fluoride (D1208) provided on June 9, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and topical application of fluoride. You
say that you should not have a copay for Medicare-covered dental services. The Plan denied your request. The
Plan says this claim processed correctly.
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, you must pay a $5 copayment for
periodic oral evaluation and topical application of fluoride each, and a $35 copayment for the prophylaxis.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis
(D1110), and topical application of fluoride (D1208) provided on June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics purchased on August 12, 2020.
You asked the Plan to pay for foot orthotics. You say that this should be covered because the provider is innetwork. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics purchased on August 12,
2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation (76770) provided July 21, 2020.
You asked the Plan to pay for the diagnostic ultrasound. You say that the plan is not paying your doctors and ow they will not see you until the bills are paid. You need to see your doctor but they say you owe them $800. The Plan denied your request. The Plan says that the clinical documentation does not support medical necessity of this test.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 diagnostic ultrasound. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee complains of back pain, which though likely neuropathic from disk disease, is not clearly defined. He does have multiple risk factors for vascular disease including diabetes, hypertension and hyperlipidemia. Even without back pain symptoms, he could be considered a candidate for one time screening for an abdominal aortic aneurysm based on his age of 65 years and risk factors for peripheral vascular disease, particularly the hypertension and diabetes mellitus. These substantial risk factors now coupled with back pain symptoms, makes a one-time retroperitoneal ultrasound to rule out an abdominal aortic aneurysm both reasonable and medically necessary. The ultrasound study therefore meets CMS rules in this clinical situation. 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 diagnostic ultrasound have been met. Therefore, we decided that the Plan has to pay for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation (76770) provided July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the belt, strap, sleeve, garment, or covering, any type (A4467).
You asked the Plan to pay for the belt. You say that you had called the plan about a brace and was told that it was covered totally. You are a senior and out of work due to the virus and in no way can you pay this. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for the belt, strap, sleeve, garment, or covering, any type (A4467).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72040) provided on March 10, 2020.
You asked the Plan to pay for an x-ray. You say that procedures can be performed multiple times in the same
day. The Plan denied your request. The Plan says this was previously billed and paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that an additional unit of CPT code 72040 is not supported in the medical record. The medical record
only supports one unit of CPT code 72040, which was previously billed and paid. Based on this information,
we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan
does not have to pay for an x-ray (72040) provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower head and mucus relief provided on September 25,
2020, and September 30, 2020.
You asked the Plan to pay for shower head and mucus relief. You say that the services should be covered. The
Plan denied your request. The Plan says you have exhausted your plan benefit for these items.
The Plan must follow Medicare rules. Medicare rules say that you receive $25 a month for eligible over-the-counter
items.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of shower head and mucus relief have not been met. Specifically, records indicate you have exhausted
your plan benefits. Records show the Plan covered $27.67 in over-the-counter items for the month of
September. There is no evidence you had any of your $25 allowance leftover from the previous months. You
are responsible for any cost over the allowed amount each month. Therefore, we decided that the Plan does not
have to pay for a shower head and mucus relief provided on September 25, 2020, and September 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a
participating provider on September 1, 2020.
You asked the Plan to waive the deductible for an outpatient surgery. You say that the don't agree with the
deductible being applied to this. You say that deductibles are for hospital bills only. The Plan denied your
request. The Plan says the correct deductible amount has been applied.
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 there is a $1,000 deductible for outpatient surgery/in-network.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
surgery/in-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$1,000 deductible for outpatient surgery/in-network. This cost sharing is a contractual obligation that had not
been met at the time an outpatient surgery was received on September 1, 2020. The total amount you are being
asked to pay is $592.40. Therefore, we decided that the Plan does not have to waive the deductible for an
outpatient surgery provided by a participating provider on September 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for status epilepticus. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment bymultiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays rendered on September 8, 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 the services exceed the benefit limit.
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 one set of
four bitewing x-rays every year.
We looked at the file and the Plan's rules. The file shows that you received two sets of bitewing x-rays on
September 8, 2020. The Plan covered one set of bitewing x-rays. The second set is not covered by your
supplemental dental benefit or your medical benefit. Therefore, we decided that the Plan does not have to pay
for the bitewing x-rays rendered on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses services purchased August 21, 2020, from an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eyeglasses services. You say that you would like the Plan to cover this 
service. The Plan denied your request. The Plan says the allowance does not apply when glasses are purchased 
from an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a $150 allowance when the eyeglasses are purchased from a 
contracted provider with the Plan. 
 
We looked at the file and the Plan's rules. In this case, you purchased glasses from an OON provider. Based on 
this information, we decided that the Plan's rules for coverage of the eyeglasses services have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses services purchased August 21, 
2020, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided Julie Smahaj, APRN, on
July 21, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says nonemergent, 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 nurse practitioner services provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services (86001) provided on June 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forOOn laboratory services. You say that this should be covered.The Plan denied your request. The Plan says this was 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe laboratory services (86001) provided on June 11, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on May 18,
2020 and billed under codes 99602-SS and 99601-SS.
You asked the Plan to pay for codes 99602-SS and 99601-SS. You say that this claim should be paid. The Plan
denied your request. The Plan says codes 99602-SS and 99601-SS could not be paid due to the status code
indicator of "I". Medicare uses another code to report these services. Medicare billing criteria are not met.
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, codes Medicare rules for coverage of codes 99602-SS and 99601-SS. We are dismissing the
request for codes 99602-SS and 99601-SS cannot be paid as billed due to the status indicator of "I".
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on
May 18, 2020 and billed under codes 99602-SS and 99601-SS.