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

We decided that the Plan does not have to pay for nursing facility services (99308, 11047) provided to the
enrollee on January 11, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Current Procedural Terminology (CPT) code 99308 and 11047 remain not supported.

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 the denied codes is:

CPT 99308:

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at
least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem
focused examination; medical decision making of low complexity. Usually, the patient is responding
inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside
and on the patient's facility floor or unit

CPT 11047:

debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia) for each
additional 20 cm or part thereof.

We asked our coding 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 the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found the
documentation submitted documents a billing provider; however, the procedure report does not document this
provider's credentials. This is needed to confirm the qualified health professional performed the services.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for nursing facility services (99308, 11047) provided to the enrollee on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three periodontal maintenance services, resin-based composite, and non-prescription drugs provided from June 1, 2020, to December 7, 2020.

You asked the Plan to pay for the periodontal maintenance services, resin-based composite, and non-prescription drugs. You say that you paid for these services in full and have not received reimbursement for them. The Plan denied your request. The Plan says these services are not covered by Medicare.

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 three periodontal maintenance services, resin-based composite, and non-prescription drugs provided from June 1, 2020, to December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for an injection of a drug into the eye (67028) and an aflibercept injection (J0178) provided on February 26, 2021.

You asked the Plan to waive the cost-shares for injections. You say that this should be covered, and it is much cheaper than having surgery on the eye. The Plan denied your request. The Plan says the cost-shares you are being charged is correct.

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 20% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $40 copayment for each Medicare-covered exam to treat an eye condition.

You have been asked to pay a 20% coinsurance and a $40 copayment for injections. The records show that you had an intravitreal injection. The EOC confirms $40 is the required copayment for this service. The records also show that you had an aflibercept injection. The allowed amount of the claim is $1,843.52, resulting in a coinsurance obligation of $368.70. Your total cost share is $408.70 ($40 + $368.70 = $408.70). 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 cost-shares for an injection of a drug into the eye (67028) and an aflibercept injection (J0178) provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92004), an eye refraction (92015) and an eye exam with photos (92250) provided on March 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a medical eye exam, refraction and photos. You say that you have called for prior authorization and were told an authorization is not needed. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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 medical eye exam (92004), an eye refraction (92015) and an eye exam with photos (92250) provided on March 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on January 30, 2021.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362 and L36523 to support their denial. However, LCD L36139, L36129, L36362 and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129, L36362 and L36523 to substantiate our decision. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on January 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a medical eye exam (92012), frames (V2020) and bifocal lenses (V2200) provided on April 20, 2021.
You asked the Plan to reimburse you for a medical eye exam, frames and bifocal lenses. You say that you are
dissatisfied with the glasses that were made for you and you are seeking reimbursement of payment. The Plan
denied your request. The Plan says services were applied correctly.
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 contract says that you pay a $10 copayment for a routine eye exam every year. If you
purchase glasses (frames and lenses) outside of the provider network, you are covered for up to a $150
allowance.
We looked at the file and the Plan's rules. The records show that you had a medical eye exam and purchased
frames and bifocal lenses. The EOC confirms $10 is the required copayment for the eye exam. The records also
show that the total cost for your frames was $190. The Plan applied the $150 benefit allowance, leaving you a
balance of $32. The Plan has paid the full amount for the bifocal lenses with no cost to you. This brings your
total cost share to $42. Based on this information, we decided that the Plan's rules for coverage of a medical
eye exam, frames and bifocal lenses have not been met. Therefore, we decided that the Plan does not have to
reimburse you for a medical eye exam (92012), frames (V2020) and bifocal lenses (V2200) provided on April
20, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the
appropriate Quality Improvement Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar sacral orthosis (L0637) provided on December 21, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the item provided.
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 20% coinsurance for each Medicare-covered prosthetic or orthotic device, including replacement or repairs of such devices, and related supplies.
You have been asked to pay $178.26 (Plan allowed amount of $891.29 x 20% coinsurance) for the orthotic device provided. 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 the lumbar sacral orthosis (L0637) provided on December 21, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of an implant body (D6010), a custom fabricated abutment (D6057), and an implant supported crown (D6066) for tooth # 18.
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 implant is not listed as a covered service. The Plan says that custom fabricated abutment is not listed as a covered service. The Plan also says that implant supported crown 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 surgical placement of an implant body (D6010), a custom fabricated abutment (D6057), and an implant supported crown (D6066) for tooth # 18.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a K3 microprocessor foot.

You asked the Plan to pre-approve a K3 microprocessor foot. You say that the requested microprocessor ankle-foot system is medically necessary. You say that the enrollee is a K-3 level amputee and meets the requirements for the item in dispute. The Plan denied your request. The Plan says that the K3 microprocessor foot does not meet the Medicare criteria as reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a K3 microprocessor foot. Our reviewer says that a K3 microprocessor foot is considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation that the enrollee is a K3 ambulator and medical notes from the prescribing provider do indicate that the microprocessor foot should be attached.

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 K3 microprocessor foot have been met. Therefore, we decided that the Plan has to pre-approve a K3 microprocessor foot.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric services after August 16, 2021.

You asked the Plan to pre-approve the continued inpatient mental health care. You say that you need additional inpatient mental health services. The Plan denied your request. The Plan says the inpatient psychiatric care was covered through August 15, 2021, but as of August 16, 2021, you have reached reasonable expectations for improvement and are medically stable. You can be stepped down to a less intensive level of care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 continued inpatient mental health care. Our reviewer says that as of August 16, 2021, the inpatient mental health services were no longer medically necessary in the requested setting. Our physician reviewer found that you were involuntarily admitted to an acute inpatient psychiatric hospitalization on July 24, 2021. Based on a review of the records, it does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than at a lower level beyond the dates covered by the Plan. You do not have dangerousness to self or others, and you are compliant with your treatment. It does not appear that inpatient services are reasonably expected to improve your condition for the purpose of diagnosis beyond the dates in question. Based on a review of the records, you do not meet the criteria for continued acute inpatient mental health treatment as of August 16, 2021 going forward. The health Plan's denial of continued inpatient psychiatric services is appropriate in this case. 

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 continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric services after August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for post cataract vision hardware provided March 30, 2021.

You asked the Plan to pay for the vision services. You say that you called the Plan before you had the glasses 
made and was told not to use standard equipment, do medical. You asked about this provider specifically and 
was told you can use them. The Plan denied your request. The Plan says enrollee's must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 these services when rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. Your routine vision hardware benefit allows you to use both in 
network and out of network providers with a maximum benefit allowance of $100. Your medical vision 
hardware benefit requires you to use an in-network provider. The services were processed under the medical 
vision hardware benefit. Therefore, you must use an in-network provider. Based on this information, we 
decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that 
the Plan does not have to pay for post cataract vision hardware provided March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 implants (D6010), an implant supported lower denture (D6111), and 4 semi-precision attachment abutments (D6052).
You asked the Plan to pre-approve the implants, implant supported denture, and the semi-precision attachment abutments. You say that the services are medically necessary. The Plan denied your request. The Plan says that implants, implant supported denture, and the semi-precision attachment abutments 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 4 implants (D6010), an implant supported lower denture (D6111), and 4 semi-precision attachment abutments (D6052).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 physician services provided on January 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services coded 95955, 95885, 95937, 95908, and
95927 provided on November 2, 2020.
You asked the Plan to pay for the testing services. 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 payable.
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 95955, 95885, 95937, 95908, and 95927 are not supported in the medical record.
Specifically, the technical report did not include documentation of an electroencephalogram (EEG) during
nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified.
The technical report did not include documentation of a limited needle electromyography, per each extremity
with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity
study; (listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified.
The technical report did not include documentation of neuromuscular junction testing (repetitive stimulation,
paired stimuli), per each nerve, by any 1 method; therefore, code 95937 cannot be verified.
The technical report did not include documentation of nerve conduction studies; for 3-4 studies; therefore, code
95908 cannot be verified.
The technical report did not include documentation of a short-latency somatosensory evoked potential study,
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or
head; therefore, code 95927 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the testing services have not been
met. Therefore, we decided that the Plan does not have to pay for the testing services coded 95955, 95885,
95937, 95908, and 95927 provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (G0283) provided March 26, 2021 to March 29, 2021.

You asked the Plan to pay for the chiropractic services. You say that you need chiropractor for adjustment of spine. Without the treatment you would be in continuous pain. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (G0283) provided March 26, 2021 to March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unspecified implant procedure, by report (D6199 x 4).

You asked the Plan to pre-approve the dental services. You say that your dentures do not allow you to chew food enough to get food down your throat. The Plan denied your request. The Plan says unspecified implant procedures, by report, 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the unspecified implant procedure, by report (D6199 x 4).