Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.

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 there is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says that the denial of authorization for this device is correct, because
the record does not show that the enrollee meets the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with
diabetes who meet criteria referenced above.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide a legible copy of the medical records you submitted
with this request. We requested legible medical records, but they were not submitted by the Plan. Without this
information, the Plan has not shown that its decision to deny authorization based on the enrollee not meeting
Medicare criteria for coverage of a therapeutic CGM is medically correct or justified by Medicare rules.
Therefore, we decided that the Plan has to pre-approve a therapeutic continuous glucose monitor (CGM).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device and accessories provided on June 1, 2020, by
an OON provider.
You asked the Plan to pay for a CPAP and accessories. You say that you did not know the provider was not innetwork
and are unable to pay the bill. The Plan denied your request. The Plan says rules for OON coverage
have not been met.
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 a CPAP device and accessories provided on June
1, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the lancets provided on January 13, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the items 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay $2.59 (The Plan allowed amount of $12.97 x 20% coinsurance) for the lancets provided. 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 issue reimbursement for the lancets provided on January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit, and a diagnostic
mammogram provided on December 3, 2020.
You asked the Plan to waive the copayments for a specialist visit and a diagnostic mammogram. You say that
you feel that you should be reimbursed the full amount and a mammogram should be fully covered. 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 $30
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $20
copayment for simple diagnostic tests.
The medical records show that you received a specialist visit on December 3, 2020. Therefore, you are
responsible to pay the $30 copayment.
The medical records show that you received a diagnostic mammogram provided on December 3, 2020.
Therefore, you are responsible to pay the $20 copayment.
The total amount you owe is: $50.
You have been asked to pay the total copayment amount of $50 for a specialist visit and a diagnostic
mammogram. A specialist visit falls within the physician services, including doctor's office visits benefit
category. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and
supplies 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 copayments for a specialist visit, and a
diagnostic mammogram provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth (molar) extraction to be provided by an oral surgeon.

You asked the Plan to pre-approve tooth extraction. You say that your molar is in very bad condition and if not extracted will damage the tooth next to it. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan only covers dental services provided by a participating general dentist.

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 when performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve a tooth (molar) extraction to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, x-ray and revascularization procedure provided by an out-of-network provider on November 17, 2020
You asked the Plan to pay for the office visit, x-ray, and revascularization procedure. You say that the documentation shows the medical necessity of the service and should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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, x-ray and revascularization procedure provided by an out-of-network provider on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397) provided on October 9, 2020.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says there was no video or telephonic visit by the ordering physician to warrant the codes billed.
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 pay for a knee brace and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the right knee. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee brace have not been met. The requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and a suspension sleeve (L2397) provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and a panoramic x-ray (D0330) provided on January 7, 2021.
You asked the Plan to pay for the x-rays. You say that you did not realize these services were not covered. If your provider had told you that you would have to pay for them out of pocket, you would have denied the services. The Plan denied your request. The Plan says these x-rays are not covered under the Plan's supplemental dental benefit.
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 complete series of intraoral x-rays (D0210) and a panoramic x-ray (D0330) provided on January 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Cypionate for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self administration.
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 Testosterone Cypionate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral x-rays (D0210, D0230) and an unspecified preventative procedure (D1999) provided on January 11, 2021.
You asked the Plan to pay for the dental services. You say that you have questions about why some services were not covered on the date in question. The Plan denied your request. The Plan says intraoral x-rays and unspecified preventative procedures are not covered under the Plan's supplemental dental benefit.
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 intraoral x-rays (D0210, D0230) and an unspecified preventative procedure (D1999) provided on January 11, 2021.
Please note: in your request you specifically asked about the periodontal maintenance provided on January 11, 2021. The documentation shows that this service was paid in full upon initial submission. The services that were denied for coverage on this date have been addressed in this appeal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services 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 the services provided by an out-of-network provider on October 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 16, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the orthosis was medically necessary.
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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not reasonable and medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumber-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) received January 5, 2021.

You asked the Plan to pay for the bitewings - four radiographic images (D0274). You say that the requested service was necessary. The Plan denied your request. The Plan says you have exceeded the allowable annual frequency for this service.

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 exceeds those covered under this benefit. On this date of service, you received services D0220 and D0230, thereby exhausting this benefit for the calendar year. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) received January 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 25, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford the charges and the Plan should pay for them. 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 $225 copayment for advanced imaging services. You have been asked to pay a $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 CT scan provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (11042) provided on January 19, 2021, and
January 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair,
the column two code is denied, and the column one code is eligible for payment. Procedure code 11042 is part
of an edit pair with procedure code 11043. Procedure code 11043 is a column one code, and procedure code
11042 is a column two code. Procedure code 11043 has been billed and paid on the dates of service in question,
which means that procedure code 11042 is not eligible for payment. Therefore, we decided that the Plan does
not have to pay for the services (11042) provided on January 19, 2021, and January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of skin substitute graft services coded 15275 provided on November 11, 2020.

You asked the Plan to pay for the application of skin substitute graft services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.

We find that CPT code 15275 is not supported in the medical record. Specifically, the operative report did not include documentation to meet the guidelines of an application of skin substitute graft to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, for a total wound surface area up to 100 sq cm, for the first 25 sq cm or less wound surface area; therefore this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the application of skin substitute graft services have not been met. Therefore, we decided that the Plan does not have to pay for the application of skin substitute graft services coded 15275 provided on November 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided by an out-of-network provider on
December 14, 2020.
You asked the Plan to pay for x-ray services. You say that there was no time to obtain authorization since the
patient had to be seen right then. You say that the claim should be paid. The Plan denied your request. The Plan
says prior authorization was required but not obtained.
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 x-ray services provided by an out-of-network
provider on December 14, 2020.