Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) provided December 12, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you don't think you should have been charged to go back to the hospital for them to remove packing from you nose they put in on 12/10/20. They put in in. Told you to come back so they could remove it. Nothing else done. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $90 for each Medicare covered emergency room visit for Emergency care. You have been asked to pay $90 for each Medicare covered emergency room visit for the emergency visit. the emergency visit falls within the Emergency 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 the emergency department visit (99282) provided December 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 29.
You asked the Plan to pre-approve the crown for tooth # 29. You say that you thought this service was covered.
The Plan denied your request. The Plan says there is no radiographic evidence that a crown would be necessary
for tooth # 29.
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 dental
service 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 dental service. Our reviewer says
that the crown for tooth # 29 is not medically necessary. Our physician reviewer found the provided
documentation did not include a diagnostic radiograph of tooth # 29 nor a narrative indicating the reason for
the need for a crown restoration. Therefore, the reviewer found that the criteria for the requested crown for
tooth # 29 has not been met.
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 dental service have not been met. Therefore, we decided that the Plan does
not have to pre-approve a crown (D2740) for tooth # 29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is out-of-network. The Plan says that these services must be provided by a participating 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 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 genetic testing provided on December 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (HCPCS S1015 and S8301) provided to the enrollee on October 26, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these are invalid procedure codes for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (HCPCS S1015 and S8301) provided to the enrollee on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose meter and supplies (K0553, K0554) provided January 14, 2021.
You asked the Plan to pay for the continuous glucose meter and supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the member's medical condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records submitted do not show that the provider discussed the medical need for the durable medical equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose meter and supplies (K0553, K0554) provided January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of cervical dystonia. She has not tried and failed the Plan's required drug, Xeomin. The records do not show that the required drug would be contraindicated or less effective; therefore, Botox is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyOwn Skin substitute.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that skin substitutes are covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary.
Our physician reviewer found the enrollee has what is described as a venous insufficiency ulcer. The record consists of one office note from the requesting physician as well as a testimonial letter without medical records. The submitted information is insufficient to support that the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyOwn Skin substitute.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited (problem focused) oral evaluation (D0140), extractions (D7210), osseous surgery (D7950) and nitrous oxide analgesia (D9230) provided on January 25, 2021.
You asked the Plan to pay for the dental services. You say that you needed to use an out-of-network provider due to the pandemic and pain you were experiencing with your teeth. You feel an exception for coverage should be made for these services. The Plan denied your request. The Plan says these dental services are not covered by your dental benefit, regardless of the network status of the dentist who provides the care.
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 a limited (problem focused) oral evaluation (D0140), extractions (D7210), osseous surgery (D7950) and nitrous oxide analgesia (D9230) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) chiropractic manipulative treatment (98943) provided April 14, 2020 to May 26, 2020.
You asked the Plan to pay for the chiropractic services. You say that you are urging the plan to reconsider the denial and hopefully make a broad policy change. If the plan cannot do that, then you are asking to make an exception in your case. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99212) chiropractic manipulative treatment (98943) provided April 14, 2020 to May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of the broken complete denture base, maxillary (D5512) received November 18, 2020.
You asked the Plan to pay for the repair of the broken complete denture base. You say that you were in pain and needed to repair your denture. The Plan denied your request. The Plan says you do not have a dental benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the repair of the broken complete denture base, maxillary (D5512) received November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) provided January 19, 2021.
You asked the Plan to pay for the periodic oral exam, dental cleaning and bitewing x-rays. You say that you have been going to this dentist for years and expected the Plan to cover at least part of the cost. The Plan denied your request. The Plan says the provider who rendered the services does not participate in Medicare and therefore the services are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. We looked at the file and Medicare rules. In this case the dental provider who rendered the services has opted out of Original Medicare. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) provided January 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 30, 2020, to December 30, 2020.
You asked the Plan to pay for the SNF services. You say that these services are coverable under Medicare Act. The Plan denied your request. The Plan says there were no daily skilled nurse or daily skilled therapy need on the dates of service in this case.
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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 30, 2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223, 99233) provided on May 14, 2019, to May 18, 2019.
You asked the Plan to pay for hospital care. You say that this should be covered. The Plan denied your request. The Plan says the documents do not support these codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT codes 99223 and 99233 are not supported in the medical record. Specifically, medical records have not been submitted for the billed dates of service. Without this documentation, the billed codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99223, 99233) provided on May 14, 2019, to May 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency ambulance transport (A0429) provided on September 22, 2020.
You asked the Plan to pay for an emergency ambulance transport. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support medical necessity for emergency ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 an emergency ambulance transport. Our reviewer says that documentation does not support than the emergency ambulance transport was medically reasonable and necessary. The documentation also does not support that another means of transport were contraindicated in this case. Our physician reviewer found the enrollee had multiple medical problems including osteomyelitis of the left foot which was non-healing. The enrollee was being admitted to a rehabilitation & nursing facility. The enrollee had no complaints.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an emergency ambulance transport have not been met. Specifically, criteria for medical necessity of an emergency ambulance transport were not met. Therefore, we decided that the Plan does not have to pay for an emergency ambulance transport (A0429) provided on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on
October 1, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies
coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients
with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
hereditary cardiovascular screening panel testing provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 lab work provided on December 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression wrap identified with code A6549.

You asked the Plan to pre-approve the compression wrap. You say that your arm is getting larger due to a blockage.The Plan denied your request. The Plan says you do not meet medical criteria.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve gradient compression wrap identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a ventilator. You say that you have advanced stage COPD.The Plan denied your request. The Plan says there is no documentation that you have hypercarbia or hypoxemia that is not already adequately treated with supplemental oxygen.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 ventilator. Our physician reviewer found that you have COPD, but there is no documentation of carbon dioxideretention, done when you are stable.  Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP devices can provide the support mode that has been ordered for the ventilator. Therefore, the requested home ventilator is not considered 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 a ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530)provided on October 13, 2020.

You asked the Plan to pay for therapeutic activities. You say that this should be covered.The Plan denied your request. The Plan says this was not billed correctly.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were provided in a home health setting. There is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met.

Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on October 13,2020.