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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), and the bitewing x-rays (D0274) provided on February 2, 2021.
You asked the Plan to pay for the dental services. You say that this dentist is in network. You say that the provider's office confirmed that they were in network. You say that after you received the services you found out that the provider was not in network until the next day. You also say that these services should be covered as in network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network are not covered.
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 the services are listed as covered, dental services performed out of network are not among those covered under this benefit. Additionally, the record shows that the Plan confirmed with the provider that the balance for these services has been written off. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), and the bitewing x-rays (D0274) provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says needs can be safely met in an outpatient therapy setting.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a
stroke and lower extremity weakness. Medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct POS code.
We looked at the file and Medicare rules. The file shows that procedure code 99213 (office visit) was billed with Place of Service (POS) code 12 for a home setting. This POS code is not appropriate for the billing of an office visit. Therefore, we decided that the Plan does not have to pay for the office visit rendered on January 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the PT in the home (S9131) and HH care (Q5001) provided from December 1, 2020, to December 22, 2020 by an OON provider.
You asked the Plan to pay for the PT and HH care. You say that you would like this claim to be reconsidered for coverage. The Plan denied your request. The Plan says these services were rendered by a non-network provider. The Plan also says that the enrollee was referred by another non-network provider, and prior authorization was not obtained.
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 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 PT in the home (S9131) and HH care (Q5001) provided from December 1, 2020, to December 22, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463) provided on November 16, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $55 for each Medicare-covered urgent care provider visit. You have been asked to pay a $28.53 copayment for the urgent care visit provided. This is the Plan's allowed amount which is less than the applicable copayment for this service.
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 hospital outpatient clinic visit (G0463) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on February 12, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the correct POS code. 

We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed with Place of Service (POS) code 12 for a home setting. This POS code is not appropriate for the billing of an office visit. Therefore, we decided that the Plan does not have to pay for the office visit rendered on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on February 2, 2021.
You asked the Plan to pay for the pulp vitality tests. You say that you understood that this service would be covered at 50%. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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.
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 pulp vitality tests (D0460) provided on February 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy rendered on January 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 45385 and 45380 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. In this case, the CPT Code Manual definition of code 45385 is colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. The definition of code 45380 is colonoscopy, flexible; with biopsy, single or multiple.
We find that CPT codes 45385 and 45380 are not supported in the medical record. Specifically, the operative report does not contain documentation of a flexible colonoscopy with removal of tumors, polyps, or other lesions by snare technique to support code 45385. The operative report does not include documentation of a flexible colonoscopy with biopsy to support code 45380. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy rendered on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor supplies for the enrollee.
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor supplies for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 26, 2020.
You asked the Plan to pay for the drug testing. 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. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is 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 a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the endoscopy provided on January 21, 2020.
You asked the Plan to waive the coinsurance for the endoscopy. You say that you received a bill beyond any reasonable time to complete billing for a medical procedure. You say that the charge should be written off. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each outpatient hospital facility visit. You have been asked to pay $471.28, which is 20% of the allowed amount for the endoscopy. The allowed amount is $2,356.44 (20% x $2,356.44 = $471.28). The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 coinsurance for the endoscopy provided on January 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the care the enrollee needs can continue in a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high-intensity focused ultrasound (HIFU) treatment.
You asked the Plan to pre-approve HIFU treatment. You say that there is ample evidence in peer-reviewed literature that HIFU treatment for prostate cancer is an appropriate and reasonable therapy in a selected patient such as this enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's prostate cancer is not a recurrence and has not been previously treated with radiation therapy.
The Plan follows Medicare rules. Medicare rules state that HIFU may be covered under certain specific clinical circumstances. 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 HIFU treatment. Our reviewer says that the enrollee does not meet the Medicare criteria for HIFU. Our physician reviewer found Medicare only covers HIFU as a salvage treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HIFU treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve high-intensity focused ultrasound (HIFU) treatment.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for airway compromise. The enrollee received an emergency tracheotomy but is not on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 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 ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are
available in-network.
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 services to
be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the core build up (D2950) and crown (D2740) provided on November 10, 2020.
You asked the Plan to reimburse you for the dental services. You say that you were never advised that your plan had changed. You say that you made 3 phone calls prior to receiving the services to verify that the services would be covered. You say that you were told you could submit the bill for reimbursement. You also say that you would not have had the work done if you knew the services would not be covered.
The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that 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 core build up and crown are not among those covered under this benefit. Additionally, the record shows that the Plan sent you an Annual Notice of Changes for 2020 on September 14, 2019. Therefore, we decided that the Plan does not have to reimburse you for the core build up (D2950) and crown (D2740) provided on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the external ambulatory insulin delivery system (A9274).
You asked the Plan to pre-approve the external ambulatory insulin delivery system. You say that this request is medically necessary as you are running out of the item. The Plan denied your request. The Plan says this is not a covered service under your medical benefit.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are non-covered device. We looked at the file and Medicare rules. Based on this information, we decided that Medicare statutorily does not provide coverage for the external ambulatory insulin delivery system. Therefore, we decided that the Plan does not have to pre-approve the external ambulatory insulin delivery system (A9274).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (99203) provided on December 11, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the services were rendered
to the provider for a problem that was not related to their current hospice diagnosis. The Plan denied your
request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is
revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering
services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the outpatient visit (99203) provided on December 11, 2020.