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

We decided that the Plan does not have to pay for the debridement services (11042, 11043, 11044) rendered by
the out-of-network (OON) provider on March 24, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the debridement services (11042, 11043, 11044) rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (99223, 99232) from December 15, 2020, through December 21, 2020.
You asked the Plan to pay for inpatient services. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the codes billed for December 15, 2020, and December 21, 2020 are 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.
We asked our coder 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 inpatient services. Our reviewer says that services provided on December 15, 2020, and December 21, 2020 do not meet criteria for billing or reimbursement consideration. Our coder reviewer found the medical records provided do not include sufficient documentation to support subsequent hospital care, per day, for the evaluation and management of an enrollee. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Specifically, the medical records provided do not include sufficient documentation to support subsequent hospital care, per day, for the evaluation and management of an enrollee. Therefore, we decided that the Plan does not have to pay for inpatient services (99223, 99232) from December 15, 2020, through December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter. 
 
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Dexcom G6 transmitter. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found in this case; the record indicates 
that the enrollee has diabetes. The enrollee uses insulin three times daily. The record does not indicate that the 
enrollee adjusts the insulin dose frequently based upon the glucose reading. The elements of the coverage rule 
are not satisfied. The requested service cannot be recommended. 

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 Dexcom G6 transmitter have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 transmitter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete set of dentures (D5110, D5120). 
 
You asked the Plan to pre-approve a set of dentures. You say that your dentures are broken and you are unable 
to eat solid food. The Plan denied your request. The Plan says rules for coverage have not been met because the 
Plan benefit for the requested item has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a set of 
dentures once every 5 years.  
 
We looked at the file, the Plan contract, and Medicare rules. Based on this information, we decided that the 
Plan's rules for coverage of a set of dentures have not been met. Specifically, the record indicates that your 
previous set of dentures was provided in October 2019 or fewer than 5 years ago. At this time you have 
exhausted the Plan maximum benefit for coverage of a set of dentures. Therefore, we decided that the Plan 
does not have to pre-approve a complete set of dentures (D5110, D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services (98941) provided February 1, 2021 to February 4, 2021.

You asked the Plan to waive the copayment for chiropractic services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for chiropractic services. 

You have been asked to pay a $20 copayment for chiropractic services. Chiropractic visits fall within the chiropractic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for chiropractic services (98941) provided February 1, 2021 to February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set (S1015), infection control supplies (S8301), portable gaseous oxygen system (E0431), stationary compressed gaseous oxygen system (E0424), respiratory suction pump (E0600), miscellaneous durable medical equipment (E1399), and unlisted special services (99199) provided November 12, 2020.

You asked the Plan to pay for the IV tubing extension set, infection control supplies, portable gaseous oxygen system, stationary compressed gaseous oxygen system, respiratory suction pump, miscellaneous durable medical equipment, and unlisted special services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says the coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that DMEPOS is covered only when there are both a physician order and proof of delivery.

We find that unlisted special services (99199) is not supported in the medical record. Specifically, this code should not be billed by anesthesia practitioner.

We find that the IV tubing extension set (S1015) and infection control supplies (S8301) are not supported in the medical records. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the codes are not valid for Medicare purposes.

We find that for the portable gaseous oxygen system (E0431), stationary compressed gaseous oxygen system (E0424), respiratory suction pump (E0600), and miscellaneous durable medical equipment (E1399), the record does not contain a valid] physician order. The record shows that the Plan made several attempts to obtain the necessary documentation without success.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set, infection control supplies, portable gaseous oxygen system, stationary compressed gaseous oxygen system, respiratory suction pump, miscellaneous durable medical equipment, and unlisted special services have not been met.

Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015), infection control supplies (S8301), portable gaseous oxygen system (E0431), stationary compressed gaseous oxygen system (E0424), respiratory suction pump (E0600), miscellaneous durable medical equipment (E1399), and unlisted special services (99199) provided November 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99283) provided March 24, 2021.

You asked the Plan to pay for the emergency visit. You say that kindly review and reprocess the following claim for maximum reimbursement. The Plan denied your request. The Plan says the claim was processed correctly as the diagnosis is not covered under the medical plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the emergency visit when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the emergency visit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the treatment related to the enrollee's diagnosis of periapical abscess and dental caries is directly related to the teeth and is not a covered expense. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99283) provided March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist/hand orthotics (L3916), provided on November 10, 2020.
You asked the Plan to pay for a wrist/hand orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no established relationship with the ordering physician.
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 pay for a wrist/hand orthotics. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of a credible physical examination of the wrist. 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 wrist/hand orthotics have not been met. Specifically, there is insufficient documentation of a physical evaluation, making this item not medically necessary. Therefore, we decided that the Plan does not have to pay for a wrist/hand orthotics (L3916), provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bystolic.

You asked the Plan to pre-approve Bystolic. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Plan does not have to pre-approve Bystolic.

Benefits for Bystolic 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
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 not safe to discharge
home and requires daily intervention. The Plan denied your request. The Plan says records show you have not
completed your full course of care in the hospital, you need further evaluation and surgical intervention of your
wounds. LTACHs do not provide clinical advantage over non-LTACH acute care hospitals.
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 in this case the enrollee was admitted with an infected femur fracture and sacral
wound. The enrollee continues to require surgical intervention and has not completed her course of acute care.
The enrollee continues to receive acute care services, and these have not been denied. The medical record does
not indicate that the enrollee requires services that she is not currently receiving but that would be available at
the LTACH facility. The elements of the coverage rules are not satisfied.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening; PSA test (CPT code G0103) provided on October 20, 2020.

You asked the Plan to pay for the PSA test. You say that the doctor checked your PSA levels when you had heart bypass surgery and you were unaware of what tests were being done with your blood. The Plan denied your request. The Plan says the maximum benefit has been exhausted. The Plan states they made outreach to the ordering provider and they state you were advised this was a follow-up after your bypass surgery and that is why they ordered another PSA test.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file show that you received a prostate cancer screening exam on July 13, 2020, by the same laboratory provider who performed the same test on October 20, 2020. Your 2020 EOC states that for men age 50 and older, covered services include the following - once every twelve (12) months: Digital rectal exam and PSA test. 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 pay for the prostate cancer screening; PSA test (CPT code G0103) provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) provided on March 19,
2021, by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says this provider is out-of-network, the services were not
referred by a network provider, and the services were not urgent or emergent, nor were they approved in
advance.

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 the office visit (CPT code 99213) provided on March 19, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthotics (L3960), provided on July 23, 2020.

You asked the Plan to pay for the wrist/hand orthotics. You say that the item was medically necessary and should be covered. The Plan denied your request. The Plan says the enrollee was contacted through an unsolicited telephone call.

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 the wrist/hand orthotics have not been met. Therefore, we decided that the Plan does not have to pay for the wrist/hand orthotics (L3960), provided on July 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 
7, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you feel this claim should be paid. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the documentation does not include the exercises, activities, training, and/or tasks for the 
therapy code billed. This means that the documentation does not support that the services billed were a distinct 
service. 

Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure 
coded 97110 provided on January 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belsomra for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Belsomra for the enrollee.
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed bridge comprised of a pontic (D6242) on tooth #9 and retainer crowns (D6751) for teeth #7, #8, #10 and #11.

You asked the Plan to pre-approve the fixed bridge. You say that these services are necessary. The Plan denied your request. The Plan says a bridge can only be used to replace one upper front tooth or two lower adjacent front teeth. You also cannot be missing any of the back teeth. The Plan's dentist looked at the x-rays and determined other teeth are missing in the arch. In addition, only one retainer crown on either side is permitted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a fixed bridge when it is requested to replace one upper front tooth or two adjacent lower front teeth, and there are no missing back teeth.

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 fixed bridge. Our reviewer says that the documentation is insufficient to demonstrate that the requested dental services are necessary. Our physician reviewer found the enrollee appears to have a pre-existing bridge involving teeth #8, #9 and #10. The documentation does not appear to demonstrate that these services are necessary for the teeth in question, and does not show that the Plan's criteria for coverage of a fixed bridge are met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a fixed bridge comprised of a pontic (D6242) on tooth #9 and retainer crowns (D6751) for teeth #7, #8, #10 and #11.