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

We decided that the Plan does not have to pay for a central motor evoked potential study (95939) provided on July 23, 2019.
You asked the Plan to pay for a central motor evoked potential study. You say that this code is supported as the record shows that both upper and lower limbs were monitored. The Plan denied your request. The Plan says CPT code 95928 would be more appropriate for the services rendered.
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 95939 is [*****enter CPT Codebook definition*****]. 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 central motor evoked potential study. Our reviewer says that CPT 95939 is not supported by medical records. Our physician reviewer found the documentation notes testing/monitoring of the upper extremities, but not of the lower extremities. 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 central motor evoked potential study have not been met. Therefore, we decided that the Plan does not have to pay for a central motor evoked potential study (95939) provided on July 23, 2019.
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 the enrollee is ready to transfer to the
LTACH where she will benefit. The Plan denied your request. The Plan says the denial of authorization for
LTACH service is correct.
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 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 as no acute services are required, then be transferred/discharged to a lower level of
care for any ongoing long-term care needs.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay formedical services provided on June 19 and June 26, 2018.You asked the Plan to pay forthe medical services. You say that your office was transitioning softwares and clearinghouses at the time the claim was submitted. You say that this resulted in denials not coming through. You say that you were also utilizing a third party billing company who has since been terminated. You say that the enrollee had a positive outcome and healed well due to the services provided.The Plan denied your request. The Plan says the claim in dispute was not submitted within the timely filing limits.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.There is no evidence of a valid claim for the services in dispute being submitted within the timely filing limits. The record shows that a claim for the medical services was not filed until July 8, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay formedical services provided on June 19 and June 26, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the complete series of periapical x-rays (D0210) provided on October 16, 2019.
You asked the Plan to pay for the dental services. You say that you have had mouth ulcers for more than 6 months that have not healed. You also say that you have used very little of your $2,000 worth of dental coverage. The Plan denied your request. The Plan says the oral evaluation, prophylaxis and periapical x-rays are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the prophylaxis (D1110), and the complete series of periapical x-rays (D0210) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve office services. You say that your office is in the process of becoming contracted with the Plan, and the enrollee cannot afford the higher charges that other providers charge.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network pain management specialist such. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services were not unforeseen.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the initial periapical x-ray (D0220) and the 2 additional periapical x-rays (D0230) provided on September 24, 2019.
You asked the Plan to pay the in network rate for the periapical x-rays. You say that you have been advised on multiple occasions that the provider in this case is in network. The Plan denied your request. The Plan says 1 periapical x-ray per calendar year is covered. The Plan also says that the frequency limit has been exceeded.
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 and periapical x-rays are listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for a periapical x-ray that you received on July 29, 2019. Therefore, we decided that the Plan does not have to pay the in network rate for the initial periapical x-ray (D0220) and the 2 additional periapical x-rays (D0230) provided on September 24, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on September 9, 2019.You asked the Plan to pay forlab test. You say that this test should be a covered benefit for the enrollee.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for lab test by the enrollee's in-network treating physician. This provider is a contract provider. The file does not show that the plan provided notice that lab test would not be covered. Under Medicare rules, this means lab test is considered approved by the plan.Therefore, we decided that the Plan has to pay forlaboratory testing provided on September 9, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four x-rays provided on October 15, 2019.
You asked the Plan to pay for the bitewings. You say that this was your first time having x-rays for dental work last year. The Plan denied your request. The Plan says this service has a limit on how often it can be paid in 12 months. The Plan also says that limit has already been reached.
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, bitewings are limited to once every 12 months. The record shows that you received bitewings on April 9, 2019 and your bitewings benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings - four x-rays provided on October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three surgical placements of implant bodies: endosteal implants, bone replacement graft for ridge preservation, and guided tissue regeneration provided on September 18, 2019.You asked the Plan to pay forthe three endosteal implants, bone replacement graft, and guided tissue regeneration. You say that your dentist told you that you had major issues under your bridge, and it had to be cut off with teeth and roots extracted. You also say that these services were for health reasons and not cosmetic purposes.The Plan denied your request. The Plan says these services are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe three surgical placements of implant bodies: endosteal implants, bone replacement graft for ridge preservation, and guided tissue regeneration provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee needs a power seat elevation feature for safe transfers, eye contact, independence, navigating thresholds, and reach. The Plan denied your request. The Plan says power seat elevation features are not considered medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe inpatient stay provided from October 9, 2019 through October 11, 2019 and October 11, 2019 through October 16, 2019.You asked the Plan to reduce the copayment forthe inpatient stays. You say that these were considered two separate stays. You say that you should only be charged for 5 days.The Plan denied your request. The Plan says the copayments 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 $345 copayment per day, days 1 to 5 and a $0 copayment per day, days 6 to 90 at an in-network inpatient hospital. Your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type. You have been asked to paya total of $2,070 for the inpatient stays. Date of ServiceInpatient DaysStandard CopaymentMember LiabilityOctober 9, 2019 -October 11, 20191$345 /day$345October 11, 2019-October 16, 20195$345/day$1,725TOTAL:$2,070 The inpatient stays fallwithin the "Inpatient hospital care" 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 reduce the copayment forthe inpatient stay provided from October 9, 2019 through October 11, 2019 and October 11, 2019 through October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories, cup holder, USB charger, and power seat elevation feature.
You asked the Plan to pre-approve a cup holder, USB charger, and power seat elevation feature (E2300). You say that the seat elevator is necessary for safe transfers, reach, and completing Mobility Related Activities of Daily Living. The Plan denied your request. The Plan says a cup holder, USB charger, and power seat elevation feature are not considered primarily medical and therefore are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 power wheelchair accessories, cup holder, USB charger, and power seat elevation feature.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecolchicine 0.6mg tablets.You asked the Planto pre-approvethe colchicine tablets. You say that this medication is necessary.The Plandenied your request. The Plansaysthis is an oral drug which is not covered by Medicare Part B.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 Plandoes not haveto pre-approvecolchicine 0.6mg tablets.Benefits for the colchicine tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 admission to an IRF does not meet criteria. Our physician reviewer found this enrollee presenting with subarachnoid hemorrhage (SAH) after fall with loss of consciousness. The enrollee reports the last thing he remembers was heading out of house to pick up grandchildren. Per family at bedside, he was found down on the street by his neighbors, presumably after fall. Alert and oriented at that time. Per the 2/14/20 progress note the repeat head CT is stable on 2/13. The enrollee is to follow up in 2 weeks with repeat head CT. The enrollee's prior level of function was functionally independent and has recommendation to use straight cane but per family refuses. The enrollee was independent with self-care. He frequently falls, daily and weekly. Cognitive decline noted over past year. On 2/16/20, the enrollee was medically cleared for discharge. On 2/17/20 he ambulated 50 feet x 2 with wheeled walker. He was minimal assist for sit to stand. He was minimal assist for chair transfers, minimal-moderate assist for bed mobility, standby assist/setup for grooming and activities of daily living. The enrollee needed minimal assistance with upper extremity dressing. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 additional surgical extractions (D7140), the 4 implants (D6010), and the upper partial denture (D5130) provided from August 26, 2019 to August 29, 2019 by the out of network provider.You asked the Plan to pay for4 additional extractions, 4 implants, and the upper partial denture. You say that you called the Plan prior to your appointment. You say that you were never advised that you did not have out of network benefits. You say that you do not have regular access to the internet and rely on Plan representatives for accurate information. You also say that you cannot afford to pay this bill.The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan says that the frequency limit for extractions has been exceeded. The Plan also says that implants and partial dentures are not listed as covered services.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 and extractions are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for 2 of the extractions you received on August 29, 2019. Additionally, implants and partial dentures are not listed as covered services.Therefore, we decided that the Plan does not have to pay forthe 4 additional surgical extractions (D7140), the 4 implants (D6010), and the upper partial denture (D5130) provided from August 26, 2019 to August 29, 2019 by the out of network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial collar bone removal (23120), an arthroscopy with ligament release (29826), and an arthroscopy with rotator cuff repair (29827).
You asked the Plan to pre-approve a partial collar bone removal, an arthroscopy with ligament release, and an arthroscopy with rotator cuff repair. You say that your doctor recommended surgery due your advanced condition. The Plan denied your request. The Plan says this is not medically necessary.
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 a partial collar bone removal, an arthroscopy with ligament release, and an arthroscopy with rotator cuff repair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no recent trial and failure of physical therapy for your shoulder pain. There are no immediate indications for surgery documented. 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 partial collar bone removal, an arthroscopy with ligament release, and an arthroscopy with rotator cuff repair have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial collar bone removal (23120), an arthroscopy with ligament release (29826), and an arthroscopy with rotator cuff repair (29827).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.
The enrollee asked the Plan to pay for the paramedic intercept services. The enrollee said that the denial of the
claim will cost them $1,300. The enrollee said that it should have been approved by the Plan which would have
cost the enrollee only a $50 copayment. The Plan denied the enrollee's request. The Plan says this item is not a
covered benefit.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the
services are furnished in a rural area.
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we
decided that the Plan does not have to pay for the paramedic intercept services.