Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D4263) provided on July 14, 2020.

You asked the Plan to pay for the bone replacement graft. You say that your tooth was knocked out 20 years ago and workman's compensation assisted with the matter. Recently, the implant provided fell out and required dental work. You feel this should be covered as it relates to your accidental injury 20 years ago. The Plan denied your request. The Plan says they have overturned the denial for the panoramic x-ray; however, the Plan was unable to confirm with the provider that the bone replacement graft is related to an accident or trauma within the last year. The Plan's medical policy stipulates that services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member's healing and/or skeletal somatic maturation reasonably allows for repair.

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, and there is no evidence that this service was provided due to a recent trauma within one year. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D4263) provided on July 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9366) provided from June 15, 2020, to June 19, 2020.

You asked the Plan to pay for the home infusion therapy. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not covered.

The Plan must follow Medicare rules. Medicare rules say that procedure code S9366 is not valid for Medicare purposes and is not payable. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9366) provided from June 15, 2020, to June 19, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on September 23, 2020.

You asked the Plan to pay for the chest x-ray. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on September 8, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).

You asked the Plan to pre-approve the mandibular partial denture. You say that you would like this claim to be reconsidered because it is for anterior teeth. The Plan denied your request. The Plan says there appears to be 8 or more natural or prosthetic posterior teeth in occlusion. The Plan also says that this service is only covered if there are less than 8 posterior teeth in occlusion.

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 mandibular partial denture 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 mandibular partial denture. Our reviewer says that due to the presence of adequate masticatory function, the criteria for coverage for a mandibular removable partial denture (D5214) have not been met. Our physician reviewer found the dental record and radiographs indicate that the enrollee is missing posterior teeth on the right side. Our reviewer found that it appears that with the remaining teeth, adequate masticatory function is present bilaterally. Our physician reviewer also found that a removable partial denture is not medically necessary for adequate function.

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 mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for stroke with left sided
weakness. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that you will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our
physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on November 14, 2020.

You asked the Plan to waive the coinsurance for an office visit. You say that you disagree with the charges you had COVID-19 symptoms and your primary care physician was not available to see you. 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 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits.

You received an office visit on November 14, 2020, with an out-of-network provider. Therefore, you are responsible to pay $43.16, which is less than the 50% coinsurance amount.

You have been asked to pay $43.16 for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 coinsurance for an office visit provided on November 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 22, 2020.

You asked the Plan to waive the copayment for laboratory services. You say that you were not charged for lab services in the past and disagree with 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 $0 copayment for lab services provided at a laboratory facility and a $10 copayment for laboratory services provided at an outpatient hospital facility.

The record shows that you received laboratory services at an outpatient hospital facility on May 22, 2020. Therefore, you are responsible to pay the allowed amount of $7.77, which is less than the $10 copayment.

You have been asked to pay $7.77 for laboratory services. Laboratory services fall 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 laboratory services provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating hospital on May 12, 2020, to December 17, 2020.

You asked the Plan to waive the copayment for wound care. You say that you feel like you were misled. You say that you had wound care. You say that you were unaware that wound care is considered an outpatient surgery. The Plan denied your request. The Plan says the correct copayments have 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 $150 copayment for outpatient surgery/ outpatient hospital.

You have been asked to pay a $150 copayment for each wound care. The total amount you are being asked to pay is $1,650 ($150 x 11 visits = $1,650). Wound care is considered an outpatient surgery; therefore, the correct copayment has been applied. Wound care falls within the outpatient surgery/ outpatient hospital 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 an outpatient surgery provided by a participating provider on May 12, 2020, to December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2020.

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 services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88321) provided on August 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. 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 (88321) provided on August 19, 2020.
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 you need intense therapy to get back to where you were previously.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and were treated for a stroke. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on November 4, 2020.

You asked the Plan to waive the copayment for an ambulance trip. You say that the EMT was inexperienced and could not stop the bleeding. 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 $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for an ambulance trip. Since ambulance services were provided, the correct copayment has been applied. An ambulance trip falls within the ambulance 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 waive the copayment for an ambulance trip provided by a participating provider on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint (SI) joint for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the clinical value and effectiveness of radiofrequency ablation of the SI joint, whether performed using traditional, cooled, or pulsed radiofrequency, in the setting of chronic SI joint pain has not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Cooled RFA is not covered by Medicare, only traditional RFA. RFA of the lateral sacral branches is considered experimental/investigational because of the wide variation in efficacy in the peer reviewed literature. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint (SI) joint for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on September 24, 2020.

You asked the Plan to pay for the genetic testing. 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. 

We find that CPT code 81479 is not supported in the medical record. Specifically, this code should be billed with the appropriate DEX Z code identifier. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 10, 2020.

You asked the Plan to waive the copayment for the ambulance transport. You say that the doctor from the skilled nursing facility sent you by ambulance when another mode of transportation could have been chosen. You say that you should not be responsible for the cost and the charge should be removed. 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 $295 copayment per one way trip for Medicare-covered ground ambulance services.

You have been asked to pay a $295 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 waive the copayment for the ambulance transport provided on April 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6537.

You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested items.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6537 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 compression stockings identified with code A6537.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on November 2, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you were not charged for a previous
scan and the only difference was that they used dye. 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 $200
copayment for CT scans.

You have been asked to pay the allowed amount of $192.90, which is less than the $200 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 November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening testing provided on June 8, 2020.

You asked the Plan to pay for the cardiovascular disease screening testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular disease screening testing provided on June 8, 2020.