Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe services (CPT 43499) provided on October 24, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services are not covered by Medicare.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.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 has used LCA A56863 to contend that the requested services are considered not medically necessary. However, the article in question is not applicable to the jurisdiction in which the services were provided. As A56863 is not applicable for this jurisdiction, it cannot be used to determine coverage of the services in question. The Plan has not provided documentation to substantiate its denial.Therefore, we decided that the Plan has to pay for the services (CPT 43499) provided on October 24, 2019.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 reimburse the copayment forchiropractic services provided on June 13, 2019.You asked the Plan to reimburse the copayment forchiropractic services. You say that you overpaid and should be reimbursed for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 copayment for out-of-networkchiropractic services. You received chiropractic services from an out-of-network provider on June 13, 2019. Therefore, you are responsible to pay the allowed amount of $55, which is less than the $70 copayment. You have been asked to pay $55 for chiropractic services. Chiropractic services fall within the chiropractic services 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 reimburse the copayment forchiropractic services provided on June 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ropinirole Tab 8mg Er.
You asked the Plan to pre-approve Ropinirole Tab 8mg Er. You say that the medication is necessary. The Plan
denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate
pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ropinirole Tab 8mg Er.
Benefits for Ropinirole Tab 8mg Er 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) and blood test (82274) provided on October 15, 2019.
You asked the Plan to pay for the advance care planning and blood test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted 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. In this case, the CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. The CPT Code Manual definition of 82274 is blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations. We asked our coder 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 advance care planning and blood test. Our reviewer says that CPT code 99497 does not meet criteria for billing or reimbursement consideration. The medical records provided do not state that Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate was performed on October 15, 2019, therefore, this service cannot be validated. Our reviewer found CPT code 82274 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include lab results or lab report to validate that 82274 was performed on October 15 , 2019, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the advance care planning and blood test have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497) and blood test (82274) provided on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two of the resin-based composite fillings provided on
December 18, 2019.
You asked the Plan to pay for the fillings. You say that you were not informed that this would not be covered.
The Plan denied your request. The Plan says that your benefit is exhausted.
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 two resinbased
composite (white) fillings per calendar year.
We looked at the file and Medicare rules. The file indicates that plan has already provided coverage for two
fillings this year. Based on this information, we decided that the Plan's rules for coverage of the fillings have
not been met. Therefore, we decided that the Plan does not have to pay for two of the resin-based composite
fillings provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for breast MRI (77049) provided on December 11, 2019.
You asked the Plan to pay for the MRI. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says this code is not recognized by the Outpatient
Prospective Payment System (OPPS) and an alternate code for the same service may be available.
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 77049 is not supported in the record. Specifically, per the OPPS, CPT code 77049 has a
status indicator of B. This means that this code is not recognized or paid under OPPS when billed on an
outpatient hospital bill type. Based on this information, we decided that Medicare rules for coverage of the
MRI have not been met. Therefore, we decided that the Plan does not have to pay for breast MRI (77049)
provided on December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from November 27, 2019 through December 4, 2019.You asked the Plan to pay for SNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from November 27, 2019 through December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build-up services (CPT D2950).
You asked the Plan to pre-approve the core build-up services. You say that core build-up services are medically necessary. The Plan denied your request. The Plan says the service in dispute is not a covered benefit under your contract.
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 pre-approve core build-up services (CPT D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for CoViD-19. The enrollee was intubated/ventilated twice and eventually received a tracheotomy. The enrollee has been weaned from the ventilator to a tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that you assisted with services and should be compensated. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no referring provider listed on the claim.
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 has network providers available who can provide 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 chronic care management provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing rendered on November 27, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare. The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing rendered on November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that the enrollee is no longer able to self-propel a manual wheelchair The Plan denied your request. The Plan says documentation does not show a power wheelchair is medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown for tooth #9.
You asked the Plan to pre-approve the crown. You say that you were told this service was a covered part of your dental plan. The Plan denied your request. The Plan says this service is not a covered 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 pre-approve the crown for tooth #9.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive metabolic panel provided to the enrollee on December 24, 2019.You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are not authorized for the diagnosis listed on the claim.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, the testing services, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive metabolic panel provided to the enrollee on December 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an office or outpatient visit (99212) provided on December 7, 2019.You asked the Plan to pay for the office or outpatient visit. You say that you would like reconsideration as this claim was billed correctly.The Plan denied your request. The Plan says CPT code 99212 is not appropriate for an inpatient place of treatment.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 99212 is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99212 is not supported in the record. Specifically, CPT code 99212 is for an office or outpatient visit. It is not appropriate to bill this code with POS 23, or, emergency department except for specific exceptions. There are no records to indicate whether the service meets the exception criteria. Based on this information, we decided that Medicare rules for coverage of the office or outpatient visit have not been met.Therefore, we decided that the Plan does not have to pay for an office or outpatient visit (99212) provided on December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for meningococcal vaccines (90620, 90734) and administration (90471) provided on January 6, 2020.
You asked the Plan to pay for meningococcal vaccines and administration. You say that this was medically necessary. The Plan denied your request. The Plan says preventative vaccines are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide meningococcal vaccines and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to meningococcal vaccines and administration. Therefore, we decided that the Plan does not have to pay for meningococcal vaccines (90620, 90734) and administration (90471) provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehearing aids.You asked the Plan to pre-approvethe hearing aids. You say that you sought an independent opinion who toldyou that you have 50% hearing loss in both ears. You state the second opinion was done and the audiologist informed you that you had 50% hearing loss in both ears.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. The request is still denied. This is becauseaccording to Medicare Benefit Policy Manual Chapter 16, hearing aids (a device placed into your ear to help you hear better) are not covered by Medicare. In addition, according to the Plan: Hearing Aids criteria, the Plan covers hearing aids when all of the following are present: a   signed prescription from an otolaryngologist (a doctor who treats conditions of the ears, nose and throat) or your attending physician; a   signed examination of your ear, nose and throat; a signed an audiology (hearing) report and hearing aid evaluation. We looked at the medical records that your doctor sent us. There was no signed prescription found, and there was no examination of your ear, nose and throat thatwas performed. Therefore, we arenot ableto approve your request at this time. Please continue to follow up with your Primary Care Provider and specialists for any health care concerns you might have.Therefore, we decided that the Plan does not have to pre-approvehearing aids.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dialysis circuit procedure provided on October 23, 2019.You asked the Plan to waive the copayment for the dialysis circuit procedure. You say that the surgery was unsuccessful.You say that you shouldn't be charged a copayment.The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for in-network, Medicare-covered surgical, IV therapy and blood transfusion services.You have been asked to pay a $250 copayment for the dialysis circuit procedure. The dialysis circuit procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the surgery was performed. 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 dialysis circuit procedure provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided by an OON dentist on September 4, 2019.You asked the Plan to pay for the prophylaxis. You say that you did not know that this provider was not in-network and thought the cleaning would be covered.The Plan denied your request. The Plan says the treating provider does not participate with your Plan network. The Plan also says that services are not a covered benefit when they are rendered by a dentist who does not participate with your plan.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the prophylaxis provided by an OON dentist on September 4, 2019.