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

We decided that the Plan does not have to pay for mandibular partial denture - resin base (including,
retentive/clasping materials, rests, and teeth) (D5212) and maxillary partial denture - resin base (including,
retentive/clasping materials, rests, and teeth) (D5211) provided on March 2, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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. You exhausted your $1,000 maximum benefit allowance. Your EOC
states, "there is a $1,000 combined allowance for supplemental preventive and comprehensive services every
year. Member is responsible for any amount over and above the allowance amount." Therefore, you are
responsible for any amount over and above the $1,000 allowance amount. Therefore, we decided that the Plan
does not have to pay for mandibular partial denture - resin base (including, retentive/clasping materials, rests,
and teeth) (D5212) and maxillary partial denture - resin base (including, retentive/clasping materials, rests, and
teeth) (D5211) provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient  (D0150) provided on March 3,2020.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your benefit frequency limit.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 itemsor services are not among those covered under this benefit. You exhausted your benefit frequency limit, because you had this service performed on October 7, 2019. Your EOC states, comprehensive oral evaluation -Frequency/Limitations -One (1) procedure every three (3) years.Therefore, we decided that the Plan does not have to pay forcomprehensive oral evaluation -new or established patient  (D0150) provided on March 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the enrollee's cardiovascular status is not stable due to acute deterioration with new arrhythmia. The Plan says that the enrollee still requires treatment with a Cardizem and amiodarone drip. The Plan says that the enrollee requires 5 liters of supplemental oxygen. The Plan says that the records do not show services which are required for an LTACH admissionto be medically necessary. The Plan says that the enrollee's care can be continued at a higher level of care in the acute inpatient hospital.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 enrollee was admitted with acute respiratory failure and hypoxia. The hospital course included IV antibiotics and chest tube and was complicated by atrial fibrillation. The enrollee is still requiring a Cardizem and amiodarone drip. He is also currently requiring supplemental oxygen. The enrollee appears to still require acute care services based on the above, however, they do not require services at the LTACH that are not already available at the current acute care facility. There are no services available at the LTACH that the enrollee requires that are not already available at the current acute care facility.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on December 20, 2019.You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 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 diagnostic radiology services provided on December 20, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for PN/INR testing (G0429) billed for dates of service February 27, 2020 through March 12, 2020.
You asked the Plan to pay for the PN/INR testing. You say that you would like reconsideration because this was billed in accordance with Medicare guidelines. The Plan denied your request. The Plan says this code has a frequency limitation of no more than one unit per 25 days which as been exceeded.
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the correct code to describe the services rendered. The rules also say that testing with the home PT/INR system should not be done more than once per week. In this case, the definition of the code G0249 is Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PN/INR testing have not been met. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare. Evidence was submitted showing that payment for this code was made on February 20, 2020 which would include payment for four weekly tests. Payment of this code weekly would indicate testing four times per week, which is not covered by Medicare guidelines.
Therefore, we decided that the Plan does not have to pay for PN/INR testing (G0429) billed for dates of service February 27, 2020 through March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for apheresis (36514) and related procedures (77002, 29914) provided on February 4, 2020.
You asked the Plan to pay for apheresis and related procedures. You say that these services should be paid. The Plan denied your request. The Plan says these services are not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that apheresis is covered for the above listed conditions.
We looked at the file and Medicare rules. The record does not show that the enrollee had any of the covered
conditions. Based on this information, we decided that Medicare rules for coverage of apheresis and related
procedures have not been met. Therefore, we decided that the Plan does not have to pay for apheresis (36514)
and related procedures (77002, 29914) provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 10, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because these services were rendered by two separate providers. The Plan denied your request. The Plan says that this surgical code was submitted by a provider with an anesthesia specialty.
The Plan must follow Medicare rules. Medicare rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the retrobulbar injection have been met. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 10, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2019.
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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical pathology consultation provided on October 8, 2019 billed with code 80500-26-59.
You asked the Plan to pay for the services as billed. You say that this is separately payable when billed with the -26 modifier since it is not included in the hospital bill. The Plan denied your request. The Plan says this code cannot be billed with modifier -26.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 80500 has a Pro/Tech flag of 0 in the Physician Fee Schedule. This means that the code describes physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers 26 and TC cannot be used with these codes. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the clinical pathology consultation provided on October 8, 2019 billed with code 80500-26-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foradjunctive pre-diagnostic test that aids in detection of mucosal abnormalities includingpremalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided on February 13, 2020.You asked the Plan to pay forthe dental services. You say that you and the provider called and were advised that it is a covered item and you are allowed to have this once a year.The Plan denied your request. The Plan says per previous call to the provider on May 13, 2020, the provider did not call to verify benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay foradjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for humidifier, heated, used with positive airway pressure device (E0562), filter, disposable, used with positive airway pressure device (A7038), full face mask used with positive airway pressure device, each (A7030) and headgear used with positive airway pressure device (A7035) provided to the enrollee on March 10, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that communication was never clear regarding the possible cost-share for this plan. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
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 the enrollee received DME provided on March 10, 2020. The enrollee is asked to pay 10% coinsurance for any DME received. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for humidifier, heated, used with positive airway pressure device (E0562), filter, disposable, used with positive airway pressure device (A7038), full face mask used with positive airway pressure device, each (A7030) and headgear used with positive airway pressure device (A7035) provided to the enrollee on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on January 6, 2020.
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 services are not covered when performed 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. The file shows that the
provider submitted a claim for procedure codes 97112 (neuromuscular reeducation), 97032 (electrical
stimulation), 97016 (vasopneumatic devices), 96372 (diagnostic injection), J3490 (unclassified drugs), J3420
(Vitamin B-12 injection), J3415 (pyridoxine HCl injection), and J3411 (thiamind HCl injection). Therefore, we
decided that the Plan does not have to pay for the services rendered on January 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on January 2, 2020.You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the ordering/referring provider in this case are not network providers with the Plan. 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 surgical pathology services provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2020 by an out of network (OON) provider.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 rendered are not a covered benefit when provided by an OON provider.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 has network providers available who can provide 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 laboratory services provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.You asked the Plan to pre-approve these services. You say that this is medically necessary.The Plan denied your request. The Plan says that the mobility evaluation does not include objective assessment of standing balance and gait.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 these services. Our reviewer says that a power wheelchair is not medically reasonable and necessary in this case. You have a personal mobility deficit but it is not clear that it impairs participation in MRADLs in the home as the documentation does not reveal your current functional level for your individual MRADLS. You state that you are unable to complete ADLs such as shopping and running errands which are not MRADLs in the home. The documentation is not clear why you cannot use a manual wheelchair as the medical office visit does not document an upper extremity neuromuscular evaluation and you have enough strength to use a walker. Additionally, your lower strength testing differs on the 3/23/20 visit and the 4/10/20 seating evaluation. There is no evidence of increased tone, spasticity, intermittent catheterization, or consistent evidence of edema on the medical office visit progress notes. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 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 has network providers available who can provide 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 an office visit provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy. You say that these services were provided in a skilled nursing facility. You say that these services are provided in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring skilled nursing facility is also out-of-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 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 has network providers available who can provide 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 psychotherapy provided on January 9, 2020 by an out of network (OON) provider.