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

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on November 17, 2020.

You asked the Plan to reimburse you for the periodontal maintenance. You say that you were advised by a plan representative on the online chat to submit your paid bill and you would be reimbursed. You say that had you been told the dentist had to be in network, you would have gone to a different dentist. You also say that you should be reimbursed in full for the services. The Plan denied your request. The Plan says periodontal maintenance 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, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
August 18, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code(s): 81404 and 81439) provided to the enrollee on October 19, 2020, by a non-participating provider.
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 not covered by Medicare.
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. The enrollee had cardiovascular risk assessment testing on October 19, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment 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 (CPT code(s): 81404 and 81439) provided to the enrollee on October 19, 2020, by a non-participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on October 15, 2020.
You asked the Plan to pay for the outpatient clinic visit. The Plan denied your request. The Plan says prior authorization was not 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 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 outpatient clinic visit provided by an out-of-network provider on October 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Omnipod insulin delivery system.

You asked the Plan to pre-approve the Omnipod insulin system. You say that this is medically necessary. The
Plan denied your request. The Plan says this is not covered by Medicare Part B. Part D coverage may be
available for this.

The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, such as the
Omnipod, are not covered by Medicare Part B as they do not meet the definition of durable medical equipment.

Although this may be appropriate for the enrollee, neither Medicare nor the Plan covers this device. Therefore,
we decided that the Plan does not have to pre-approve an Omnipod insulin delivery system.

Benefits for the Omnipod insulin system 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 the prophylaxis, bitewing x-rays and comprehensive oral evaluation provided on December 18, 2020.

You asked the Plan to pay for the prophylaxis, bitewing x-rays and comprehensive oral evaluation. You say that you were advised in-network providers weren't taking new patients. You say that the services would have been covered if you went in-network. The Plan denied your request. The Plan says this provider does not participate with 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis, bitewing x-rays and comprehensive oral evaluation provided on December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 11, 2020, to August 18, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you have never been charged for more than five days. The Plan denied your request. The Plan says the correct copayment has been 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 $345 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $345 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,725 ($345 x 5 days = $1,725 + $0 (days 6-7) = $1,725). An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on August 11, 2020, to August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0481) provided to the enrollee on September 9, 2020, by a non-participating provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 laboratory services have not been met. CPT 80307 (1 Unit) remains not supported. The documentation submitted did not include a valid physician order/lab requisition (signed by the ordering physician) stating exactly what tests are to be performed to support presumptive drug testing, any number of drug classes. It is noted that multiple attempts were made to obtain additional information from the provider. Healthcare Common Procedure Coding System (HCPCS) G0481 (1 Unit) remains not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0481) provided to the enrollee on September 9, 2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 21, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was contacted and indicated they received a phone call from the provider offering a back brace.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual unless the individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item. We looked at the file and Medicare rules. The Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the orthosis. As such no payment may be made for this item. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic images (D0350 x 4) provided on October 28, 2020.

You asked the Plan to pay for the dental services. You say that you went to see this dentist for an annual check up. You say that you were not aware that there would be additional charges. You say that you think this is a very shady practice with this provider. You also say that this vendor should be removed from the plan's network. The Plan denied your request. The Plan says 2D oral or facial photographic images are not listed as covered services. The Plan also says that you did not verify with the Plan that the services would be covered prior to receiving them.

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, 2D oral or facial photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic images (D0350 x 4) provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on October 5, 2020 to December 5, 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 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 5, 2020 to December 5, 2020 by an out of network (OON) provider.
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 are appealing the denied authorization for inpatient rehab and the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the clinical information does not support medical necessity for an acute rehabilitation stay. The information received indicates that your condition can be managed a a skilled nursing facility or in a long-term care facility.
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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve Intracept. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Intracept procedure is not covered by Medicare.

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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is still considered experimental/investigational. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. 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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for the treatment of low back pain. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided on October 1, 2020, to November 30, 2020.
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says the services were not medically necessary because the records show the enrollee's condition had improved by October 1, 2020.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient psychiatric hospital services were not medically necessary. Our physician reviewer found it did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this patient does not meet the criteria for treatment in an
acute inpatient mental health treatment beyond the date in question of October 1, 2020 forward and could have been treated in a lesser restrictive setting as the patient was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided on October 1, 2020, to November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no
skilled nursing or therapy service needed on a daily basis.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and did not
require supplemental oxygen. There are no identifiable skilled nursing service needs. Regarding rehab services,
the enrollee was at a moderate to maximal assist level for functional mobility. He required varying assist with
activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not
require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of
service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 direct skilled nursing services of a RN in the HH or hospice setting (G0299 x8).

You asked the Plan to pre-approve the direct skilled nursing services of a RN in the HH or hospice setting. The Plan denied your request. The Plan says the notes do not show that the enrollee has a medical problem that needs special care that only a skilled person can do.

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 direct skilled nursing services of a RN in the HH or hospice setting. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires skilled nursing services to provide treatment that is medically necessary. Our reviewer found that the enrollee does not require skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Our physician reviewer also found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 direct skilled nursing services of a RN in the HH or hospice setting have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 direct skilled nursing services of a RN in the HH or hospice setting (G0299 x8).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of an implant body (D6010) for tooth # 9 provided on November 24, 2020.

You asked the Plan to pay for the dental service. You say that the implant was necessary. You say that you were experiencing pain. You say that you had bone loss and cannot eat properly. You also say that the dentist is in network and should inform you what is covered and what is not. The Plan denied your request. The Plan says placement of an implant body is not 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 placement of an implant body (D6010) for tooth # 9 provided on November 24, 2020.