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

We decided that the Plan does not have to pre-approve scaling in presence of generalized moderate or severe gingival inflammation (D4346) and oral hygiene instructions (D1330).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says scaling in presence of generalized moderate or severe gingival inflammation is not listed as a covered service. The Plan says that oral hygiene instruction is not listed as a covered service either.
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 scaling in presence of generalized moderate or severe gingival inflammation (D4346) and oral hygiene instructions (D1330).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided January 27, 2021, through February 2, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that he 7-day hospital stay was unnecessary, and you are unhappy with the charges. The Plan denied your request. The Plan says the copayment was 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 $390 copayment each day for days 1-5 for Medicare-covered hospital You have been asked to pay a total of $1,950 ($390 copayment x 5 days = $1,950) for the inpatient hospital stay. This service falls within 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 waive the copayment for the inpatient hospital stay provided January 27, 2021, through February 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you cannot walk properly due to an accident. You say you require physical therapy for a lumbar fracture, and you do not have resources to help you and you cannot drive due to your condition. The Plan denied your request. The Plan says you have used your benefit of transport services.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when eighteen (18) (one way) trips.
We looked at your request, the records in the case file, and the rules. The file shows that you have you're your benefit and the Plan cannot covered additional routine transportation trips for this year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found there are no clinical notes provided to rationalize treatment. The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the Teeter Inversion Table purchased before February 26, 2021.
You asked the Plan to reimburse for the table. You say that you are requesting reimbursement for a Teeter Inversion Table. The Plan denied your request. The Plan says your request is not a covered benefit because your provider did not order this device for you and your medical records do not support that there is a medical necessity for this device.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the table have not been met. Review of the file shows that you purchased a Teeter FitSpine LX9 Inversion table on January 6, 2021, directly from Teeter. The records sent by your provider indicate that you had a televisit on February 3, 2021, with your provider and you mentioned that you had bilateral hip pain/back pain. During this televisit, you requested a prescription for the already purchased inversion table. There is no indication that the provider had recommended this device for you prior to purchase or that there was a medical necessity for this specific device/manufacturer/model. There is no description of your symptoms, prior treatments, or rehabilitation therapy assessment. Therefore, we decided that the Plan does not have to reimburse for the Teeter Inversion Table purchased before February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper and lower denture (D5110 and D5120).

You asked the Plan to pay for the complete upper and lower denture (D5110 and D5120). You say that you were told the office would refund the check back to the Plan so you could go somewhere else. You say that you never received dentures and you want to have teeth again. The Plan denied your request. The Plan says the service exceeds the maximum count allowed per period.

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, you also have a maximum benefit of one complete upper and lower denture every five plan years. The Plan paid for complete upper and lower dentures on September 11, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the complete upper and lower denture (D5110 and D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that you doctor does not approve of Monovisc and Orthovisc. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc-One. Our reviewer says that the requirements for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not outline contraindications or reasons these medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingrix vaccination provided on April 12, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you were offered this during your medical appointment and were told it would be covered. The Plan denied your request. The Plan says this vaccine is not covered by Medicare Part B. This must be submitted to your Part D plan for reimbursement.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or recently directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccination provided on April 12, 2021.
Benefits for the shingles vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided from January 27, 2021, through January 31, 2021.
You asked the Plan to waive the copayment for skilled nursing facility services. You say that you should not have to pay the charges. The Plan denied your request. The Plan says the copayment was 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 $0 copay per day for days 1-20, $150 copay per day for days 21-38 and $0 copay per day for days 39-100 for skilled nursing facility care. You have been asked to pay $750 for skilled nursing facility services. The services at issue fall within the skilled nursing facility 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 waive the copayment for skilled nursing facility services provided from January 27, 2021, through January 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.
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. The record shows that a claim for the laboratory services was not filed until January 26, 2021. 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 for the laboratory services provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a higher allowance for your Healthy Food Card.
You asked the Plan to pre-approve a higher allowance for your Healthy Food Card. You say that you need a higher allowance to buy extra healthy foods such as vegetables that will help bring up your hemoglobin level. The Plan denied your request. The Plan says the Plan covers $50 per month and once the money allocated to the card each month is utilized (or if all/portion is unused at the end of the month), there is no exception that allows the plan to deposit additional money to the member's Healthy Food card.
The Plan added a supplemental Health Food benefit mid-year, which is documented online. The benefit provides a $50 allowance a month.
We looked at the file and the Plan's rules. The Plan provides a $50 allowance a month for the Health Food benefit. Therefore, we decided that the Plan does not have to pre-approve a higher allowance for your Healthy Food Card.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on April 9, 2021. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says Documentation submitted did not include a valid Proof of Delivery, or a Delivery 
Ticket. Provider did not bill with modifier "CR" as per Covid 19 Pandemic guidelines.  
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. The proof of delivery is not itemized so the billed codes cannot be verified. Additionally, it is not 
signed. There is an exception, but then the billed code should have a modifier of CR per the COVID 19 
Pandemic guidelines. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis 
with suspension sleeve (L1833, L2397) provided to the enrollee on April 9, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee and family strongly disagree with the initial determination and feel the enrollee does meet the criteria for this admission. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for abdominal pain and chronic mesenteric ischemia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0823).

You asked the Plan to pre-approve a power wheelchair (K0823). You say that the requested power wheelchair (K0823) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair (K0823).

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 power wheelchair (K0823). Our reviewer says that the enrollee does not meet criteria for the requested power wheelchair (K0823). Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets criteria for the requested power wheelchair (K0823). Records do not document that the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home and that his mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair and that he can safely operate a power mobility device. 

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 power wheelchair (K0823) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0823).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home physician visit (99350) provided July 2, 2020. 
 
You asked the Plan to pay for the home physician visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation 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 99350 is home visit by a physician or non-physician 
practitioner such as a physician assistant (PA) or nurse practitioner (NP). 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, the record does not show the 
visit was performed by a physician or non-physician practitioner. Based on this information, we decided that Medicare rules for coverage of the home physician visit have not been met. Therefore, we decided that the Plan 
does not have to pay for a home physician visit (99350) provided July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87532, 
87541, 87581, 87634, 87640, and 87798 provided on September 8, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87486, 87496, 87498, 87532, 87541, 87581, 87634, 87640, and 87798 are not 
supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect 
the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in an office setting place of service 11; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in a skilled nursing facility setting place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
87486, 87496, 87498, 87532, 87541, 87581, 87634, 87640, and 87798 provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87086) provided January 29, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation 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 87086 is Culture, bacterial; quantitative colony count, urine. 

We find that CPT code 87086 is not supported in the medical record. Specifically, the documentation provided did not include lab results for this test. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87086) provided January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for chiropractic care from August 25, 2020 to October 27, 2020.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. The Plan says while part of these service was approved, the medical records show the services provided after June 8, 2020 were maintenance care which is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. Based on the medical records provided, there was no reported improvement from June to October. This is now considered maintenance care which is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for chiropractic services provided from August 25, 2020 to October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that these services were medically necessary for the enrollee and should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care or the testing provided, which is required by the Plan contract.
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 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 lab services provided to the enrollee on March 3, 2021 by an out-of-network (OON) provider.