Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bedside food tray.

You asked the Plan to pre-approve a bedside food tray. You say that this equipment is necessary for use with the hospital bed. The Plan denied your request. The Plan says this is not primarily used for a medical purpose and not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a bedside food tray.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services (97110).
You asked the Plan to pre-approve additional physical therapy services. You say that additional services are necessary for the enrollee to achieve functional independence and safety. The Plan denied your request. The Plan says additional services are not medically necessary.
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 additional physical therapy services. 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 the enrollee has had prior therapy and has been instructed in a home exercise program that she has been compliant with. 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 additional physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services (97110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for routine vision hardware provided on
April 9, 2021.

You asked the Plan to pay an additional amount for the routine vision hardware. The Plan denied your request.
The Plan says the Plan paid the maximum benefit allowance of $220, exhausting the routine vision hardware
benefit for 2021.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum benefit allowance
of $220, exhausting the routine vision hardware benefit for 2021. Therefore, we decided that the Plan does not
have to pay an additional amount for routine vision hardware provided on April 9, 2021.
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) provided on May 25, 2021.

You asked the Plan to pay for the complete x-ray series. You say that this bill is expensive, and you would appreciate a reduction in what you owe. The Plan denied your request. The Plan says this service is not covered by your 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) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient dermatology office visits coded as 99204, 11102, 11103, 14301, 14302, 17311, 17312, 17315 and 14040 provided October 9, 2020 to November 4, 2020.

You asked the Plan to pay for the office visits. You say that you are appealing for the denial for reimbursement, and the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says If you go to a provider who is not eligible to participate in Medicare and/or receive non-Medicare covered services, you will be responsible for the full cost of the services you receive.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient dermatology office visits coded as 99204, 11102, 11103, 14301, 14302, 17311, 17312, 17315 and 14040 provided October 9, 2020 to November 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on December 10, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare for review.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on September 22, 2020, and October 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that as a basis for Medicare payment, the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. Medicare rules also say that Medicare does not cover routine vision services and eyewear. We looked at the file and Medicare rules. For the services provided on October 2, 2020, you did not submit a claim or any evidence to show that payment was made for these services. Additionally, the fundus photography (92250) provided on September 22, 2020, is not covered by Medicare or your plan. 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 provided to you on September 22, 2020, and October 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on March 18, 2021 by an out-of-network
(OON) provider.

You asked the Plan to pay for an x-ray. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior
authorization was not obtained by the member's primary care physician.

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 an x-ray provided on
March 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital observation care (99220) provided on May
23, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for initial hospital observation care. You say that authorization is not required for
outpatient services. You also say that the provider rendered services in good faith and thought the facility
would obtain the proper authorization. The Plan denied your request. The Plan says prior authorization must be
obtained for non-emergent services rendered by an out-of-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. The records provided for review do not show that the services at issue were urgent or
emergent. 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 initial hospital observation care (99220) provided on May 23,
2021, by an out-of-network (OON) provider.
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 IRF care is medically necessary for recovery. The
Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are
stable. There are no complex nursing or rehabilitation needs.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 2, 2021, through March 3, 2021.

You asked the Plan to pay for SNF services. You say that the services the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.

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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. The enrollee was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision level with bed mobility and a minimal assist level with transfers. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. As a practical matter, this enrollee 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 services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from February 2, 2021, through March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on March 8, 2021.

You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this item was provided by unsolicited cold call and there is no mention of any discussion or order for any brace.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for CPT code 99072.

You asked the Plan to pay for the services. The Plan says that the services are supported.

We decided that the Plan has to pay for CPT code 99211.

The Plan follows 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 99211 is supported in the medical record. Specifically, the services in question were billed with diagnosis code Z20.828. The diagnosis code that the Plan is recommending, U07.1, would only be used if you had a confirmed case of coronavirus. The Plan has not provided any evidence or argument that showing that you had a confirmed case of coronavirus. Additionally, CPT 99211 is the correct code for an evaluation and management visit that resulted in a coronavirus test. Based on this information, we decided that Medicare rules for coverage of the services have been met Therefore, we decided that the Plan has to pay for CPT code 99211.

We also decided that the Plan does not have to pay for CPT code 99072.

The Plan follows Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the code 99072. 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 CPT code 99072.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical, each additional film (D0230) provided
May 4, 2021.
You asked the Plan to pay for the dental services. You say that your copay is $50 so why do you have to pay
$93. You only had x-rays done. You are only going to pay your copay which is $50 for this service. Please
consider this decision so that you only have to pay $50. The Plan denied your request. The Plan says this
request exceeds the benefit frequency limitation.
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. This service is covered one
procedure code per calendar year. The records show the Plan has already reimbursed for intra-oral x-rays for
date of service May 44, 2021. 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-periapical, each additional film (D0230) provided May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit (90832) provided on April 7, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a psychotherapy visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 psychotherapy visit (90832) provided on April 7, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Standing frame/table system, multi-position (E0641).
You asked the Plan to pre-approve the standing frame system. You say that it is a medical necessity because
you can only transfer out of bed with the help of your physical therapist due to safety concerns. Your doctor
and physical therapist feel this would greatly improve your quality of life and safety. The Plan denied your
request. The Plan says standing tables are non-covered because they are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve Standing frame/table system, multi-position (E0641).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 11, 2021.

You asked the Plan to pay for the eye refraction. You say that this service was performed due to a medical emergency and should be covered. The Plan denied your request. The Plan says eye refractions are not covered by Original Medicare. This service can be covered by the Plan's supplemental benefit only when it is provided by the specified routine vision vendor as part of a routine vision exam. Because the services provided on this date were medical in nature, payment is denied.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eye refractions when they are provided as part of a routine (non-medical) eye exam and received from a provider within the Plan's specified routine vision network. 

We looked at the file and the Plan's rules. Medicare does not cover eye refractions. This refraction was not routine in nature and was provided due to a medical emergency by a provider outside of the Plan's specified network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nursing facility care visit (99305) and debridement of skin
(11042, 11043) provided on March 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a nursing facility care visit and debridement of skin. You say that the services
were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained
for non-emergent services rendered by an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 nursing facility care visit (99305) and debridement of skin (11042, 11043) provided on March 23, 2021, by an out-of-network (OON) provider.