Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on October 7, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you are unhappy with the service you received and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $120 copayment for emergency care. The medical records showthat you had an ER visit on October 7, 2019. Therefore, you are responsible to pay the $120 copayment. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ER visit provided on October 7, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to make a decision on this type of complaint.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome health services provided to the enrollee on June 18, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere was no 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 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 thatwould require the Plan to pay for these items/services.Therefore, we decided that the Plandoes not haveto pay forhome health services provided to the enrollee on June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional surgical extractions (D7210).You asked the Plan to pre-approve5 additional surgical extractions. You say that you have congestive heart failure. You say that you need all 5 teeth extracted because it affects your heart. You also say that you currently have a bridge but still need the 7 extractions.The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan also says that the frequency limit has been reached.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 surgical extractions are covered, the frequency limit has been reached.The Plan previously approved 2 surgical extractions under authorization # 171193333. Therefore, we decided that the Plan does not have to pre-approve5 additional surgical extractions (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 9 and 11, and a pontic (D6245) for tooth # 10.
You asked the Plan to pre-approve the dental services. You say that you have an interim partial denture. You say that the enrollee has a severe gag reflex so she is unable to wear the partial denture full time. You say that the enrollee is unable to chew her food. You say that having the bridge will aide in the enrollee's ability to chew her food in proper occlusion. The Plan denied your request. The Plan says the retainer crowns and the pontic are not 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 retainer crowns and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 9 and 11, and a pontic (D6245) for tooth # 10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 the services are not medically necessary. Our physician reviewer found the submitted records show that you have a history of diabetes and use only long-acting glucose. The records show that you have not had hospital care related to blood sugars. Your blood sugar levels are stable. You have been instructed to check your finger daily but are refusing to do so due to finger pain. The records do not support that the requested CGM is reasonable or medically necessary at this time, as your diabetes has been well-controlled and stable with your current management plan.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 decidedthat the Plan does not have to pre-approvea continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent hospital care rendered on September 11, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99233 is 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 99233 is level three subsequent hospital inpatient care, typically 35 minutes per day.We find that CPT code 99233 is not supported in the medical record. Specifically, there are no medical records for this date of service to support that the services were rendered. 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 forthe subsequent hospital care rendered on September 11, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits, endovenous ablation therapy, and duplex scan to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe office visits, endovenous ablation therapy, and duplex scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network 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 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-approvethe office visits, endovenous ablation therapy, and duplex scan to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of the respiratory assist device.You asked the Plan to pre-approvecontinued use of the respiratory assist device (E0471). You say that you need to continue to use the respiratory assist device.The Plan denied yourrequest. The Plan says you were not compliant during your trial period.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you were not compliant and there is no statement from your physician. Based on this information, we decided that Medicare rules for coverage of continued use of the respiratory assist device (E0471) have not been met.Therefore, we decidedthat the Plan does not have to pre-approvecontinued rentalof the respiratory assist device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental anesthesia for dental extractions.
You asked the Plan to pre-approve dental anesthesia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 dental anesthesia for dental extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe office visit and methyl prednisolone acetate injection provided on January 10, 2019.You asked the Plan to waive the cost share forthe office visit and methylprednisolone acetate injection. You say that you are wondering why your copayment is so high.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for each specialist visit for Medicare-covered benefits and 10% of the cost for Medicare Part B prescription drugs. You have been asked to pay a total of $26.45 for the office visit and methylprednisolone acetate injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on April 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit. 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.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 haveto pay forthe office visit provided on April 9, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that thePlan does not have to pay forthe first intraoral periapical x-ray, porcelain crown, and core buildup, including any pins when required provided on September 12, 2019.You asked the Plan to pay forthe intraoral periapical x-ray, crown, and core buildup. You say that the provider said he would write off $458 in addition to $697. The Plan denied your request. The Plan says according to your benefits, the maximum the Plan will pay for covered dental services is $1,000 per plan year. The Plan also says that the amounts written off by the provider are deducted from the amount you owe the provider and not from the amounts the plan has paid.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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on February 21, 2019 and your annual deductible benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray, porcelain crown, and core buildup, including any pins when required provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on August 16, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on August 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99283 provided on August 9, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 99283 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. We find that CPT code 99283 is not supported in the medical record. Specifically, this service was billed with an inappropriate or invalid modifier for the code submitted. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99283 provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the porcelain fused to high noble metal crown (D2850) provided on October 30, 2018.You asked the Plan to reimburse you for the dental service. You say that you have been seeing this provider for years. You say also that they had performed most of the dental work that you have had done.The Plan denied your request. The Plan says crowns are not a covered service.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 crown is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you for the porcelain fused to high noble metal crown (D2850) provided on October 30, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a different skilled nursing facility (SNF).You asked the Plan to pre-approvethe admission to a different SNF. You say that the enrollee needs this care and should be allowed to go to a different SNF.The Plan denied your request. The Plan says there is no clinical need for continued care to provided at a new facility.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pre-approve the admission to a different SNF. Our reviewer says that daily skilled care can be provided in the current setting. Our physician reviewer found the beneficiary is a 74 year old male with CVA with left hemiparesis admitted to the SNF after LTAC stay. From a nursing perspective, the beneficiary received enteral nutrition and medications. The beneficiary had stable vital signs. He was alert with periods of confusion. He was treated for aUTI. He used oxygen via nasal cannula. Regarding rehabilitation services, the beneficiary received PT, ST and OT in the SNF. By the dates in question, the beneficiary required maximal assist with bed mobility and transfers and required minimal to moderateassist for EOB sitting balance. The beneficiary required assist with ADLs. He remained NPO and received dysphagia therapy.There is no evidence in the file that there is a medical reason which justifies admission to a new facility. All medically necessary care can be provided in the current SNF. 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 admission to a different SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a different skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arterial blood withdrawal provided on October 8, 2019.You asked the Plan to waive the copayment for arterial blood withdrawal. You say that you disagree with how the service was coded.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $40 copayment for each specialist visit. You have been asked to pay the allowed amount of$28.74, which is less than the $40 copayment for arterial blood withdrawal. Arterial blood withdrawal falls within the physician/practitioner services, including doctor's office visits 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 forarterial blood withdrawal provided on October 8, 2019.