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

We decided that the Plan does not have to pay for dental services provided and billed under codes D0150, D1110 and D0274.

You asked the Plan to pay for these dental services. You say that these dental services were medically necessary. The Plan denied your request. The Plan says based on the Plan contract agreement, code D0150 is covered once every three years. The Plan states per the claim history, this service was provided, which is within the three-year limitation. The Plan also states codes D0274 and D1110 are covered services, however the annual maximum limit of $500.00 had been reached prior to the processing the claim.

Medicare 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 dental services provided were exhausted. Therefore, we decided that the Plan does not have to pay for dental services provided and billed under codes D0150, D1110 and D0274.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for LTACH care. The Plan denied your request. The Plan says the enrollee's needs are met at the current 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 is receiving appropriate care at the present acute care hospital. At the time of the request, the enrollee's status is stable. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy (15830). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that excision, excessive skin and subcutaneous tissue will 
only be considered reasonable and medically necessary when these procedures are performed due to another 
surgery being done at the same time and would effect the healing of the surgical incision. Additionally, this 
procedure may be considered to be medically necessary for the patient that has had a significant weight-loss 
following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or 
tissue necrosis that is unresponsive to oral or topical medication. 
 
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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that the documentation does not support that 
the enrollee is having another surgery being performed at the same time of the requested panniculectomy and 
the enrollee does not have medical complications such as candidiasis, intertrigo, or tissue necrosis that is 
unresponsive to oral or topical medication. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a panniculectomy (15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the foot orthotic is medically necessary for the
enrollee. 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 pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve azathioprine.

You asked the Plan to pre-approve these services. You say that the medication has always been covered. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 azathioprine.

Benefits for these services 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: 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 appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time. 

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 waive the copayment for a specialist visit provided on September 24, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the specialist 
charges because your primary care physician is no longer accepting patients. 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 $45 
copayment for specialist doctor visits.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the doctor 
visits 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 a specialist visit provided on 
September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bunionectomy on the left foot.

You asked the Plan to pre-approve a bunionectomy (28299). You say that The Plan denied your request. The Plan says the services are not medically necessary.

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 a bunionectomy (28299). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found because of the enclosed progress note, which is confusing as to which foot is being examined, and which foot has been recommended for surgical intervention, it is my opinion that the requested left bunionectomy is not medically reasonable or necessary at this time. Medicare does indeed cover correction of a malformed body member. A bunion (hallux valgus) is a biomechanical malformation of the great toe joint. Correction of this type of deformity is considered medically necessary, but only when the recommended painful foot is examined properly and proper documentation of the surgical foot is noted. As stated above, it is unclear in the most recent progress note as to which foot is painful, which foot was examined, and which foot is being recommended for surgical correction.

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 bunionectomy (28299) have not been met. Therefore, we decided that the Plan does not have to pre-approve a bunionectomy on the left foot.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because denying this service is in conflict with NCCN national practice guidelines. The Plan denied your request. The Plan says to report a CGP, service providers should use CPT code81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when certain criteria are met. One unit of CPT code 81479 is used to report this testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, this service has not been billed correctly. To bill Guardant360 testing, one unit of CPT code 81479 must is billed. Therefore, we decided that the Plan does not have to pay for Guardant360 testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427, A0425) 
provided November 2, 2019. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you believed the 
ambulance service copayment would be waived since the enrollee was admitted to the hospital. The Plan 
denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $200 copayment for each one-way Medicare-covered ground trip by ambulance. 
 
The enrollee has been asked to pay a $200 copayment for the ambulance service. This service falls within the 
Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance service (A0427, A0425) provided November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services (96001, A5500, A5512, J0670, L1902, L1930, S0395).

You asked the Plan to pay for the podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not supported by the records provided.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 96001, A5500, A5512, J0670, L1902, L1930, & S0395 is not supported in the medical record. Specifically, CPT code S0395 has a status indicator of "I" per the National Physician's Fee Schedule. This code is not valid for Medicare purposes. No records were provided to confirm that codes 96001, A5500, A5512, J0670, L1902, & L1930 were dispensed on the date of service. The plan requested this additional information and it was not provided. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services (96001, A5500, A5512, J0670, L1902, L1930, S0395).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reimburse the cost share for services.

You asked the Plan to waive or reimburse funds you believe were overpaid for services provided in 2019. You say that you believe you have overpaid the maximum out of pocket (MOOP). The Plan denied your request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have been paid for each service leaving your contractual copayment expectation for the service provided.

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, there was a maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in question. Both the records and the Explanation of Benefits (that you would also have a copy of ) for each service clearly show the balance of the maximum out of pocket at the time of service. You have been asked to pay the correct amount for each service 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 or reimburse the cost share for several claims for services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the commode chair (E0163) and patient lift, bathroom or 
toilet (E0625) provided July 11, 2020, to August 24, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the commode chair and patient lift. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says you received these 
services from a provider not certified with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services unless the provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file indicates that the providers that rendered these items are not 
certified with Medicare. Based on this information, we decided that Medicare rules for coverage of the 
commode chair and patient lift have not been met. Therefore, we decided that the Plan does not have to pay for 
the commode chair (E0163) and patient lift, bathroom or toilet (E0625) provided July 11, 2020, to August 24, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the consultation. You say that you would like reconsideration because this provider has been working on research for 6 months and you would like to know what is going on. The Plan denied your request. The Plan says this provider is out-of-network and there are in-network providers available.

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 medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses provided to the enrollee and coded as L1833 and L2397.

You asked the Plan to pay for these orthoses. You say that this claim should be paid. The Plan denied your request. The Plan says the records do not show an established relationship with the ordering and billing physician.

The Plan must follow Medicare rules. The rules state that durable medical equipment is covered only when there are both a physician order, proof of delivery and the records show the order was placed appropriately. It cannot be confirmed the enrollee had a prior telehealth visit with the ordering physician which would facilitate or support the orthoses billed. Medicare coverage criteria are not met. Therefore, we decided that the Plan does not have to pay for orthoses provided to the enrollee and coded as L1833 and L2397.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 24, 
2020, to October 27, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from October 24, 2020, to October 27, 2020. Therefore, you are responsible 
to pay a $350 copayment for days 1-3 (October 24, 2020, to October 26, 2020). $350 (copayment) x 3 
(inpatient days) = $1,050.  
 
You have been asked to pay the total copayment amount of $1,050 for an inpatient hospital stay. 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 from October 24, 2020, to October 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility services.

You asked the Plan to pre-approve continued Skilled Nursing Facility services. You say that the enrollee needs
more rehab. The Plan denied your request. The Plan says the enroll is no longer benefiting from daily skilled
therapy services and the stay now appears more custodial.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 continued Skilled Nursing Facility
services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found
regarding rehabilitation services, the beneficiary received Physical Therapy and Occupational Therapy in the
SNF. By the dates in question, the beneficiary was at a maximal assist to dependent level with functional
mobility. The beneficiary required varying assist with ADLs. There are no identifiable skilled nursing service
needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing
or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service
criteria for an inpatient basis in a skilled nursing facility 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 continued Skilled Nursing Facility services have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued Skilled Nursing Facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs services that cannot be managed at home. The Plan denied your request. The Plan says the enrollee is receiving adequate and necessary intensive rehabilitation care in the inpatient rehabilitation facility (IRF). Movement to a skilled nursing facility is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has total dependence for bed mobility and transfers. No necessary services that require the specialized skill, knowledge and judgment of a skilled professional nurse have been identified. Skilled therapy needs have been identified but can be provided in an inpatient setting. As a practical matter, this enrollee does not require the services to be provided in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.