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

We decided that the Plan does not have to pay for the partial upper denture (D5225) provided on January 26, 2021.
You asked the Plan to pay for the dental service. You say that you would like this denture to be covered. You say that you have had your previous denture adjusted and modified multiple times. You say that it still does not fit properly. You also say that this was not done for cosmetic reasons. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been exceeded.
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 and partial denture is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a partial upper denture that you received on July 20, 2018. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5225) provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 powered wheelchair and accessories.
You asked the Plan to pre-approve a group 2 powered wheelchair and accessories. You say that the requested group 2 power wheelchair is medically necessary. The Plan denied your request. The Plan says although the criteria for a powered wheelchair has been met, the power tilt feature of the group 2 powered wheelchair is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a group 2 powered wheelchair is subject to the criteria listed in the Medicare rules section. 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 a group 2 powered wheelchair and accessories. Our reviewer says that the requested group 2 power wheelchair is not medically necessary. Our physician reviewer found the documentation is not consistent that you are at high risk for development of a pressure ulcer and is unable to perform a functional weight shift. There is no objective evaluation of the skin. The addendum to the January 19, 2021, note states that you have a sacral pressure ulcer but there is no objective evaluation of the skin and the review of systems integumentary system is noted to be negative for any issues. You report your "bottom hurts badly" but there is no examination indicating this is due to a pressure ulcer or skin issue. There is no evidence that you use intermittent bladder catherization or has spasticity on an objective physical exam. You do not require a drive control interface other than a hand or chin-operated standard proportional joystick. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 powered wheelchair and accessories have not been met. Because the base wheelchair cannot be covered, the accessories are not necessary. Therefore, we decided that the Plan does not have to pre-approve a group 2 powered wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 10, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the provider has no knowledge of patient coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the records indicate the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient diagnostic testing provided on October 12, 2020.
You asked the Plan to waive the copayment for the outpatient diagnostic testing. The Plan denied your request. The Plan says a separate office visit copay applies for diagnostic tests and procedures.
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 $50 for Outpatient diagnostic tests; all other diagnostic procedures and tests. You have been asked to pay $50 for the outpatient diagnostic testing. The outpatient diagnostic testing falls within the outpatient diagnostic tests 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 outpatient diagnostic testing provided on October 12, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for hip replacement surgery. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing / panels (CPT code
81479) provided to the enrollee on December 14, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the testing have not been met. Medicare denies coverage for all
cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with
suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for
cardiovascular risk assessment testing / panels (CPT code 81479) provided to the enrollee on December 14,
2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a special video electroencephalogram (EEG) (95720).

You asked the Plan to pre-approve a special video EEG. You say that you are experiencing seizures and have not been able to see any providers due to COVID. You have records but they are 2 years old ow and this is why you need the test so you can get back on track with you appointments. The Plan denied your request. The Plan says that the enrollee does not meet the criteria for special video EEG.

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 pre-approve a special video EEG. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member is said to have a history of refractory epilepsy. However, there has been a question raised about possible PNES. In such a setting it would be appropriate to perform a form of extended EEG monitoring to differentiate between epileptic and PNES events. In such a setting, performance of a long-term EEG study would be appropriate.

However, provision of this service in the inpatient hospital setting (as this request appears to be for EMU admission), at this time, the service would exceed the medically necessary level of care for the evaluation and management of the patient's condition at this time. As such while an extended EEG would be appropriate, there is not a clinical basis to warrant provision of service sin the inpatient 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 a special video EEG have been met. Therefore, we decided that the Plan has to pre-approve a special video electroencephalogram (EEG) (95720).

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy coded 97010 provided on December 11, 2019.

You asked the Plan to pay for the hot or cold packs therapy. 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 97010 is application of a modality to 1 or more areas; hot or cold packs. 

We find that CPT code 97010 is not supported in the medical record. Specifically, this service is a bundled service. This means that this service is not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy coded 97010 provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses and anti-reflective coating provided on December 02, 2020.

You asked the Plan to pay for the progressive lenses and anti-reflective coating. The Plan denied your request. The Plan says the progressive lenses and anti-reflective coating are not covered under the Member's contract under any normal circumstances.

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. 

We looked at the file and the Plan's rules. The file shows that the Plan's vision benefit for eyewear after cataract surgery does not cover progressive lenses and anti-reflective coating under any circumstances. Therefore, we decided that the Plan does not have to pay for progressive lenses and anti-reflective coating provided on December 02, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the co-payment for the inpatient hospital stay provided from September 30, 2020, to October 2, 2020.

You asked the Plan to reduce the co-payment for the inpatient hospital stay. You say that your only co-payment should be $90 for the emergency room. The Plan denied your request. The Plan says you have been asked to pay 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $393 co-payment for each day for days 1-5 per admission.

You have been asked to pay a $393 co-payment for each day of the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows you were admitted as an inpatient. 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 reduce the co-payment for the inpatient hospital stay provided from September 30, 2020, to October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
December 1, 2020.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature, ankle
rotation unit, and custom insert.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the request for a K2 prosthesis is not reasonable or necessary.

The Plan must follow Medicare rules. Medicare rules say that L5972 is covered for enrollees at a K2
ambulation level.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested L5968, L5972, and L5683 are not medically necessary as the therapy progress notes
documentation does not support that the patient is at a K2 or above level of ambulation.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prosthetic leg with an advanced foot feature, ankle rotation unit, and custom insert.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial upper denture (D5820) provided on
September 16, 2020.

You asked the Plan to pay for the dental service. You say that your dentist advised that they contacted the plan.
You say that you were advised the plan would cover half of the bill. You say that now you are being told that
the one denture that is not covered is the one that you received. You also say that you cannot afford to pay this
as you are retired and unemployed. The Plan denied your request. The Plan says partial dentures are covered
with a 50% coinsurance. The Plan says that interim partial upper denture is not specifically listed as a covered
service. The Plan also says that any services not listed are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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
interim partial upper denture (D5820) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for gauze, non-impregnated, sterile, pad size 16 sq. in. or less,
with any size adhesive border, each dressing (CPT code A6219-A1) and alginate or other fiber gelling dressing,
wound cover, sterile, pad size 16 sq. in. or less, each dressing (CPT Code A6196-A1) provided to the enrollee
on December 24, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are included in the global surgical package.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Review of medical records shows
and indicates that the service performed was related to the Chemical cauterization of hyper granulation tissue
performed on thigh wound on the same date of service. Codes A6219 and A6196 will remain upheld, as these
services are included in the global surgical package of the initial procedure 17250. Therefore, we decided that
the Plan does not have to pay for gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size
adhesive border, each dressing (CPT code A6219-A1) and alginate or other fiber gelling dressing, wound
cover, sterile, pad size 16 sq. in. or less, each dressing (CPT Code A6196-A1) provided to the enrollee on
December 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 5, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Arthrocentesis provided on September 14, 2020.

You asked the Plan to waive the copayment for the Arthrocentesis. You say that there was no facility room required and no operating room. You say that the charge should be reversed. The Plan denied your request. The Plan says the copayment applied 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay $236.45, which is less than the standard $295 copayment for the Arthrocentesis. The Arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Arthrocentesis is considered a surgical service that was billed by the hospital. 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 Arthrocentesis provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 14, 2020 by an out of network provider.

You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 for the office visit provided on October 14, 2020 by an out of network provider.