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

We decided that the Plan does not have to waive the copayment for emergency ambulance services (A0429), and non-emergency ambulance services (A0428) provided on February 17, 2021.

You asked the Plan to waive the copayment for emergency ambulance services, and non-emergency ambulance services. You say that you want the Plan to pay for the services. The Plan denied your request. The Plan says the copayments were 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 $225 copayment for ambulance services. 

The enrollee has been asked to pay a $225 copayment for emergency ambulance services, and non-emergency ambulance services. The services at issue fall 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 emergency ambulance services (A0429), and non-emergency ambulance services (A0428) provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) and
three bone replacement grafts for ridge preservation (D7953 x3) provided on January 14, 2021.

You asked the Plan to pay for the removable prosthodontic procedures and bone replacement grafts. You say
that you were advised that everything would be covered, and you would not have to pay anything. You also say
that after you had your teeth and dentures done, you were informed that the Plan would not cover some of the
final bill. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two
removable prosthodontic procedures (D5899 x2) and three bone replacement grafts for ridge preservation
(D7953 x3) provided on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided October 9, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 G0483 is not supported in the medical record. Specifically, the date of service on the claim does not match the date of service on the records. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided October 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued stay at a skilled nursing facility (SNF) provided from January 22, 2021, to February 20, 2021.

You asked the Plan to pay for the continued stay. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

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 continued stay. 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 continued stay have not been met. Therefore, we decided that the Plan does not have to pay for the continued stay at a skilled nursing facility (SNF) provided from January 22, 2021, to February 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for CX Bladder testing provided to the enrollee on January 6, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid by the Plan at the Medicare allowed rate. The Plan denied your request. The Plan says Medicare criteria for this testing were not met.
The Plan follows Medicare rules. The rules explicitly say that screening tests that do not provide a specific result are not covered. The medical records show this test was ordered as adjunct testing to a cystoscopy. The medical records do not specifically show how the results of this testing would be used to treat the enrollee. It also does not appear that the enrollee had prior authorization for this testing. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for CX Bladder testing provided to the enrollee on January 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled care visits.

You asked the Plan to pre-approve home health. You say that the enrollee's wound will get worse if skilled nursing is not approved. The Plan denied your request. The Plan says the denial of authorization for additional home health visits is correct, because the enrollee has had 41 prior visits for similar reasons and has a caregiver that has demonstrated the ability to do wound care.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve home health. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health visits. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition, beyond what was already approved by the Plan. The enrollee has had prior therapy and been instructed in a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, and that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The requested services are not part of a maintenance program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled care visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided on March 16, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-approved or emergent.
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 lab services (81455) provided on March 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services provided by a
participating provider on February 22, 2021, to February 23, 2021.

You asked the Plan to waive the copayment for observation services. You say that you do not agree with this.
You say that you were an inpatient. The Plan denied your request. The Plan says the correct copayment has
been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copayment for outpatient hospital observation.

You have been asked to pay a $100 copayment for observation services. Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient observation services. Observation services fall within the outpatient hospital observation 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 observation services provided by a participating provider on February 22, 2021, to February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 24, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every Plan year.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on January 8, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.

You asked the Plan to pre-approve twelve (12) additional PT visits. You say that you have been making progress on leg balance and mobility and you are not yet completely stable, and you want to improve. The Plan denied your request. The Plan says additional PT is not medically necessary. You can be treated with a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 twelve (12) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of available records, the enrollee does not meet CMS criteria for coverage for continued therapy. The requested physical therapy generally is not accepted as specific and based on your good progress and ability to home exercise program. You are currently functional and if your shoulder pain is causing you difficulty, that needs to be evaluated and addressed separately to provide appropriate therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively to provide treatment, a physical therapist and or under the supervision of a therapist is not necessary. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. You have shown compliance and ability to perform the home exercise program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twelve (12) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a filling (D2394) provided on February 15, 2021.
You asked the Plan to pay for a filling. You say that there are no in-network providers near you. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a filling (D2394) provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planning (D4341 x2), intraoral periapical radiographic images (D0220, D0230), a filling (D2392), and an unspecified preventive procedure (D1999) provided from February 11, 2021, through February 18, 2021.
You asked the Plan to pay for periodontal scaling and root planning, intraoral periapical radiographic images, a filling, and an unspecified preventive procedure. You say that you were not aware the services would not be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 periodontal scaling and root planning (D4341 x2), intraoral periapical radiographic images (D0220, D0230), a filling (D2392), and an unspecified preventive procedure (D1999) provided from February 11, 2021, through February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral periapical radiographic images (D0220, D0230) provided on March 30, 2021.

You asked the Plan to pay for a limited oral evaluation, and intraoral periapical radiographic images. You say that you should not be responsible for the charges. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 oral evaluation (D0140), and intraoral periapical radiographic images (D0220, D0230) provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided January 2, 2021.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the coverage criteria for this device were not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Although the order indicates that the enrollee is testing at least four times a day, the medical records indicate that the enrollee is only checking their blood glucose levels once per day. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided January 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 microprocessor knee.

You asked the Plan to pre-approve a K3 microprocessor knee. You say that this request is medically necessayr. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve K3 microprocessor knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the treating medical provider/physician documentation does not indicate that the patient requires a K3 microprocessor C leg over a mechanical K3 leg. The requested K3 microprocessor C leg exceeds the patient's medical needs in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of K3 microprocessor knee have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 microprocessor knee.
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 enrollee will strongly benefit from getting 3 hours of therapy a day. You say that the enrollee will be safer having her medical needs managed by the physicians that understand her case. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the 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. The enrollee's 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, and 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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.