Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) and administration (90471) provided on December 10, 2019.
You asked the Plan to pay for a shingles vaccine and administration. You say that this should be covered under your medial benefit. The Plan denied your request. The Plan says coverage for this vaccine is the responsibility of your Part D prescription drug benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) and administration (90471) provided on December 10, 2019.
Benefits for a shingles vaccine and administration 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 4, 2019 to December 23, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an invalid type of bill.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed with an invalid type of bill for a non-participating home health provider. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 4, 2019 to December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ferric carboxymaltose injection and intravenous infusion provided on December 4, 2019.
You asked the Plan to waive the cost share for the ferric carboxymaltose injection and intravenous infusion. You say that you are being overcharged. You say that you cannot afford the cost. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each Medicare-covered Part B drug and a $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a total of $383.77 for the ferric carboxymaltose injection and intravenous infusion.
The ferric carboxymaltose injection falls within the "Medicare Part B Prescription Drugs" benefit category. The intravenous infusion falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 cost share for the ferric carboxymaltose injection and intravenous infusion provided on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from January 4, 2019 to February 15, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means this service is not payable by Medicare. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from January 4, 2019 to February 15, 2019.
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 you are intimately familiar with the enrollee's condition and the capabilities of the short-term acute care hospitals and sub-acute inpatient providers in their community. You say that it is your professional opinion that the enrollee should be admitted immediately to the requested LTACH for continued cardiac monitoring, respiratory interventions, telemetry, and management of her other complex medical conditions with an aggressive regimen of physical rehabilitation as tolerated. You say that the LTACH utilizes physician directed protocols in conjunction with an interdisciplinary treatment team. The Plan denied your request. The Plan says LTACH services are not medically necessary. The Plan says that the enrollee is receiving appropriate care at the current acute care facility.
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 does not require services at the LTACH which are not available at the acute care hospital where treatment is currently being received. The acute care hospital is able to provide all of the services the enrollee requires. The medical records provided do not demonstrate that there are services available at the LTACH that the enrollee requires, which are not being offered by the health plan. Continued care at the acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, a sub-acute rehabilitation facility, or home with home health services.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services rendered on April 29, 2019.
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 procedure codes 95813 and 95937 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95813 is electroencephalogram (EEG) extended monitoring; greater than 1 hour. The definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT codes 95813 and 95937 are not supported in the medical record. Specifically, there is no documentation of the time spent performing the EEG to support code 95813. The documentation supports that Train of Four testing was performed, and code 95937 is not the appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the monitoring services rendered on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that the enrollee said that he cannot eat or talk with his dentures. You also say that the enrollee's dentures are less than 3 years old and the enrollee has never been able to wear them. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that the enrollee received a complete maxillary denture (D5110) on October 29, 2018 and the enrollee's complete maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on July 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the hearing aids. You say that that network providers cost too much. The Plan denied your request. The Plan says that you must receive care for a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on July 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 19, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 service 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 December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for spherocylinder, bifocal lens (V2203) U-V lens (V2755) scratch resistant coating (V2760) purchased September 13, 2019.
You asked the Plan to pay for the vision services. You say that you have submitted a request for reimbursement. You have enclosed the billing history which includes all charges incurred and trust this will facility the plans response to your request. The Plan denied your request. The Plan says this service exceeds the benefit limit.
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 when $100 toward the purchase of lens, frames and contact lenses. We looked at the file and the Plan's rules. The eye wear benefit has been exhausted. The total cost was $400. The plan applied the $100 benefit towards V2020. Therefore, the remaining balance is your responsibility.
Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for spherocylinder, bifocal lens (V2203) U-V lens (V2755) scratch resistant coating (V2760) purchased September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the ophthalmology services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network ophthalmologist's available to you that can provide the services you are requesting.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 17, 2019 to November 29, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that she was required to go to skilled nursing after a hospital stay. You say she was not there for long. 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 $15 a day copayment for days 1 through 20 of each skilled nursing facility admission. You pay a $75 a day copayment for days 21 through 44 each benefit period. You pay a $0 a day copayment for days 45 through 100 each benefit period. You have been asked to pay a $483.04 for the SNF stay. This is less than the standard copayment amount of $900 ($75 x 12 days) because you met your maximum out-of-pocket amount. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows you had already used 27 SNF days.
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 SNF stay provided from November 17, 2019 to November 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam capsules (J8499).
You asked the Plan to pre-approve the Temazepam. You say that the enrollee has been on medication to help her with sleep for years. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. The Plan also says that this drug is not covered for the enrollee's condition by Medicare Part B.
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 Temazepam capsules (J8499).
Benefits for the Temazepam 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of vertebral body fracture services coded 22310 provided on December 23, 2019.
You asked the Plan to pay for the closed treatment of vertebral body fracture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 22310 is closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing. We find that CPT code 22310 is not supported in the medical record. Specifically, the documentation submitted did not indicate that closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing was performed on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the closed treatment of vertebral body fracture services have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of vertebral body fracture services coded 22310 provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring for localization of cerebral seizure focus services provided on August 19, 2019.
You asked the Plan to pay for the monitoring for localization of cerebral seizure focus services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 95951 is monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (e.g., for presurgical localization), each 24 hours. We find that CPT code 95951 is not supported in the medical record. Specifically, the submitted documentation indicates that this service was performed, but does not indicate the start and end time of the study. The total time spent monitoring cannot be verified. Based on this information, we decided that Medicare rules for coverage of the monitoring for localization of cerebral seizure focus services have not been met. Therefore, we decided that the Plan does not have to pay for the monitoring for localization of cerebral seizure focus services provided on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80156, 80157, 80177, 80201, 80159, 80173 provided on April 8, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 80156, 80157, 80177, 80201, 80159, 80173 are not supported in the medical record. Specifically, the documentation submitted did not support Carbamazepine, Carbamazepine, Levetiracetam, Topiramate, Clozapine, and Haloperidol testing was performed. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen was collected, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80156, 80157, 80177, 80201, 80159, 80173 provided on April 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #7, retainer crowns for tooth #'s 6, 9, 10, & 11, and a pontic (D6242) for tooth #8.
You asked the Plan to pre-approve the pontic (D6240) for tooth #7, retainer crowns for tooth #'s 6, 9, 10, & 11, and pontic (D6242) for tooth #8. You say that the enrollee is not able to chew which is affecting their health and diet. You also say that the enrollee has only been using their front teeth to chew. The Plan denied your request. The Plan says the documents fail to demonstrate a specific medical condition that would preclude the use of a removable partial denture.
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 the pontic (D6240) for tooth #7, retainer crowns for tooth #'s 6, 9, 10, & 11, and pontic (D6242) for tooth #8 when the services are medically necessary and reasonable.
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 pontic (D6240) for tooth #7, retainer crowns for tooth #'s 6, 9, 10, & 11, and pontic (D6242) for tooth #8. Our reviewer says that the service is not medically necessary. Our physician reviewer found the Plan criteria does have specific requirements regarding coverage for fixed bridges. The Plan specifically allows bridgework in cases only where the space could not be filled by the use of a partial denture. Our reviewer found that the use of a partial denture would be appropriate as long as tooth #6 and #11 are used for the abutment teeth. It appears there is at least 50% bone remaining on these teeth and should be appropriate for a partial denture. Our physician reviewer also found that the use of a partial denture would be considered appropriate in this situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic (D6240) for tooth #7, retainer crowns for tooth #'s 6, 9, 10, & 11, and pontic (D6242) for tooth #8 have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #7, retainer crowns for tooth #'s 6, 9, 10, & 11, and a pontic (D6242) for tooth #8.