Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the tissue exam (88305) provided on March 9, 2020.
You asked the Plan to pay for the tissue exam. You say that you would like reconsideration because multiple specimens were examined on the same date for the same member. The Plan denied your request. The Plan says that this is a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal rights. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tissue exam have been met. Specifically, this is not a duplicate claim. The record indicates that two specimens were tested on the same date of service. The provider has billed this code with the appropriate modifier to show that the billed service was separate and distinct. Therefore, we decided that the Plan has to pay for the tissue exam (88305) provided on March 9, 2020.
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: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for diagnostic digital breast tomosynthesis (77062) provided on December 15, 2020.

You asked the Plan to hold you harmless for the diagnostic digital breast tomosynthesis. You say that you would like reconsideration because this procedure was ordered by your oncologist. The Plan denied your request. The Plan says that this is a non-covered procedure.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the diagnostic digital breast tomosynthesis by a contract provider. The file does not show that the Plan provided notice that the diagnostic digital breast tomosynthesis would not be covered. Under Medicare rules, this means the diagnostic digital breast tomosynthesis is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for diagnostic digital breast tomosynthesis (77062) provided on December 15, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for medical services you received from an out-of-network provider from November 12, 2018, to March 11, 2019.

You asked the Plan to waive the cost sharing for the medical services. You say that you think these charges are too high for treatment that didn't work. The Plan denied your request. The Plan says you were charged these cost sharing amounts 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 out-of-network outpatient diagnostic tests, surgical procedures, and physician services in 2018, and a $45 copayment for specialist visits with an out-of-network provider in 2019.

You have been asked to pay 20% coinsurance for the medical services you received in 2018 from an out-of-network provider. You have also been asked to pay a $45 copayment for each of the three office visits you had with this out-of-network provider in 2019. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. These amounts apply regardless of whether you believe the treatment was successful. Therefore, we decided that the Plan does not have to waive the cost sharing for medical services you received from an out-of-network provider from November 12, 2018, to March 11, 2019.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee has a history of respiratory failure and is living at home with deconditioning and weakness. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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: 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture
after a fall. She was discharged to skilled nursing on 6/30/21. Medical conditions are stable. There are no
complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
can be provided in a different 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 waive the copayments for the office visit (99213), the transthoracic echocardiography (93306), myocardial strain imaging (93356), and the interrogation device evaluations (remote), up to 90 days (93295, 93296) provided from March 10, 2020, through February 11, 2021.

Additionally, the Plan does not have to waive the copayments for the interrogation device evaluations (remote), up to 30 days (93297) provided on July 17, 2020, August 21, 2020, November 3, 2020, and January 8, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 you must pay a $50 copayment for diagnostic procedures and tests. Additionally, you must pay a $50 copayment for physician specialist services. 

You have been asked to pay $358.12 ($50 copay x 5=$250) + ($27.03 copay x 4=$108.12) for the physician specialist visit and the diagnostic tests provided. This amount is less than the applicable copayments for these services. 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 copayments for the office visit (99213), the transthoracic echocardiography (93306), myocardial strain imaging (93356), and the interrogation device evaluations (remote), up to 90 days (93295, 93296) provided from March 10, 2020, through February 11, 2021. Additionally, the Plan does not have to waive the copayments for the interrogation device evaluations (remote), up to 30 days (93297) provided on July 17, 2020, August 21, 2020, November 3, 2020, and January 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that it is medically necessary to receive services more frequently than what home rehabilitation is allowing. The Plan denied your request. The Plan says the medical records received from your healthcare provider did not show that you need daily skilled nursing care or skilled therapy because you can receive home health care therapy to increase your strength and learn how to transfer to and from your wheelchair in your home environment.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that you remain medically stable. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services (B4157) provided on March 2, 2021, by an out of network (OON) provider.

You asked the Plan to pay for the infusion services. You say that you would like this claim reprocessed for medical necessity.The Plan denied your request. The Plan says this is not a covered service.

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 infusion services (B4157) provided on March 2, 2021, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the oral exam (D0120), the initial periapical x-ray (D0220), the additional periapical x-rays (D0230 x 2), and the bitewing x-rays (D0274) provided on January 27, 2021.

You asked the Plan to pay for the dental services. You say that the provider in this case is listed in the plan's Provider Directory as in network.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by a provider that has opted out of Medicare. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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, dental service performed out of network are not covered under this benefit. The record shows that only certain providers at this office are listed as in network. The provider in this case is not listed and therefore the services are not covered.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), the oral exam (D0120), the initial periapical x-ray (D0220), the additional periapical x-rays (D0230 x 2), and the bitewing x-rays (D0274) provided on January 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services provided on
February 4, 2021.
You asked the Plan to pay for medical nutrition therapy services. You say that the medical nutrition therapy services are medically necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and catheter insertion provided by an out-ofnetwork
provider on November 9, 2020.
You asked the Plan to pay for the office visit and catheter insertion. You say that you submitted medical
records to be reviewed for further processing. The Plan denied your request. The Plan says this provider is not a
participating provider with 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
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 and catheter insertion provided by
an out-of-network provider on November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Oxycodone, Pantoprazole, and Losartan provided on March 1, 2021.
You asked the Plan to pay for the Oxycodone, Pantoprazole, and Losartan. You say that you followed the instructions from the medical personnel, and do not consider these to be self-administered drugs. The Plan denied your request. The Plan says these drugs are self-administered.
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 pay for the Oxycodone, Pantoprazole, and Losartan provided on March 1, 2021.
Benefits for the Oxycodone, Pantoprazole, and Losartan 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's needs are non-skilled in nature.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the low-level laser treatment (S8948) provided on March 17, 2020.
You asked the Plan to pay for the low-level laser treatment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S8948 has a status indicator of I and is not valid for Medicare purposes.
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 S8948 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S8948 has a status indicator of I. This means that CPT code S8948 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the low-level laser treatment have not been met. Therefore, we decided that the Plan does not have to pay for the low-level laser treatment (S8948) provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings of the upper right,
lower right, upper left, and lower left quadrants provided on January 12, 2021, and January 19, 2021.
You asked the Plan to pay for the scalings and planings. You say that you were not advised that the periodontal
scalings and root planings were limited to once every three years. You also say that in 2020, the periodontal
scalings and root planings benefit was limited to once every year. The Plan denied your request. The Plan says
benefits for these services have been satisfied and the frequency limitation 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, periodontal scaling and root planing is
limited to one procedure code every three years, per quadrant. The record shows that you received periodontal
scalings and root planings of the upper right and lower right quadrants on January 8, 2020, and periodontal
scalings and root planings of the upper left and lower left quadrants on January 14, 2020, and your periodontal
scaling and root planing benefit for each quadrant has been exhausted. Therefore, we decided that the Plan does
not have to pay for the periodontal scalings and root planings of the upper right, lower right, upper left, and
lower left quadrants provided on January 12, 2021, and January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on March 8, 2021.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not emergent. There were 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 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 services at issue in this appeal. 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 an office visit (99214) provided on March 8, 2021.