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

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180), and an intraoral complete series of radiographic images (D0210) provided on March 18, 2021.
You asked the Plan to pay for a comprehensive periodontal evaluation, and an intraoral complete series of radiographic images. You say that you thought this provider was in-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive periodontal evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a comprehensive periodontal evaluation (D0180), and an intraoral complete series of radiographic images (D0210) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on March 14, 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the
same specialty must bill and be paid as though they were a single physician. s billed on the same day and paid by the Plan. Code 99221 (initial hospital care) was billed by the same
group practice and not separately payable. Therefore, we decided that the Plan does not have to pay for the
initial hospital care rendered on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system, expandable controller, harness, electric connection, and seat cushion.

You asked the Plan to pre-approve power seat elevation system, expandable controller, harness, electric connection, and seat cushion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for certain indications.

The requested power seat elevation system does not service a primary medical purpose and is statutorily non-covered. The requested expandable controller is not covered since the approved power options come with their own switches. The requested harness is only covered when the requested expandable controller is covered. The requested electric connection's sole function of the connection is for a power seat elevation; therefore, is not covered. The seat cushion requested is a replacement because the approved wheelchair already comes with a cushion and covers.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation system, expandable controller, harness, electric connection, and seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system, expandable controller, harness, electric connection, and seat cushion.
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 service is medically necessary. The 
Plan denied your request. The Plan says the service 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 enrollee's wound care orders are for twice a day dressing changes to the right foot 
and continues on IV antibiotics. There is no documentation provided indicating medical necessity for 
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does no require services at the LTACH that are not available where currently receiving care. 
 
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. Specifically, medically necessary 
services are being provided at the current level of care and the LTACH is not offer any additional services this enrollee needs. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we 
decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply for a continuous glucose monitor (K0553) provided on October 16, 2020.
You asked the Plan to pay for a supply for a continuous glucose monitor. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the medical necessity of the requested items is not supported by the records provided.
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 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 pay for a supply for a continuous glucose monitor. Our reviewer says that the requested items are not medically necessary in this case. Our physician reviewer found that the record does not indicate that the enrollee adjusts insulin dose frequently based upon blood sugar. The elements of the coverage criteria 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 a supply for a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a supply for a continuous glucose monitor (K0553) provided on October 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 6, 2020.
You asked the Plan to pay for the subsequent nursing facility care. You say that this service is eligible for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. 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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 9, 2021, to April 11, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you feel that you should not be getting charged for medications you already have and for the lack of communication you received. The Plan denied your request. The Plan says the medications received were self-administered medications and were denied correctly as non-covered.

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 pay for the self-administered drugs provided from April 9, 2021, to April 11, 2021.

Benefits for the self-administered drugs 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 out-of-network eye surgery at the in-network cost-sharing rate.
You asked the Plan to pre-approve out-of-network eye surgery at the in-network cost-sharing rate. You say that the enrollee needs this service. The Plan denied your request. The Plan says while this service has been approved, the enrollee will be charged the out-of-network cost sharing.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). PPOs must furnish all services in-network and out-of-network but may charge higher cost-sharing for plan covered services obtained out-of-network. The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient surgery services received in-network and a 35% coinsurance for outpatient surgery services received out-of-network. The enrollee has been asked to pay a 35% coinsurance for out-of-network eye surgery. 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. 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 cover the requested surgery at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve out-of-network eye surgery at the in-network cost-sharing rate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast biopsy provided on January 21, 2021.
You asked the Plan to waive the copayment for the breast biopsy. You say that you plan does not have a copayment for an ultrasound. You say there should not be a copayment on this claim. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $200 copayment for all other outpatient services not provided in an ambulatory surgical center.
You have been asked to pay a $200 copayment for the breast biopsy. The breast biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were charged a copayment for the biopsy. The record shows you were not charged a copayment for the ultrasound.
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 breast biopsy provided on January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on January 22, 2021.
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you should not be responsible for the copayment. You say a second scan had to be done because the ultrasound was performed on the wrong area of your abdomen. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $50 copayment for specialty physician for other Medicare-covered outpatient diagnostic tests.
You have been asked to pay a $50 copayment for the abdominal ultrasound. The abdominal ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the ultrasound was completed for a diagnosis of lower abdominal pain. 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 abdominal ultrasound provided on January 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia (J0897) Injection, denosumab, 1 mg. You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has first not tried and failed zoledronic acid.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Prolia (J0897) Injection, denosumab, 1 mg. Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) Injection, denosumab, 1 mg have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
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 care could be received in another 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
coronary artery bypass grafting. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient long-term acute care hospital (LTACH).

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to the LTACH.

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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient
basis. 

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 admission to an inpatient long-term acute care hospital (LTACH).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for homecare services provided to the enrollee from January 11, 
2021, to January 29, 2021. 
 
You asked the Plan to pay for the services. You say that due to the enrollee's advanced age, frailty, and debility, 
she is having issues with activities of daily living such as toileting, cooking, transferring, and managing her 
medications. The Plan denied your request. The Plan says this service is not a Medicare-covered benefit and is 
excluded from coverage. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found no records related 
to the dates of service in question were submitted for review. No records showing that the enrollee was 
receiving skilled services during the dates of service in question were submitted for review. As such, the 
documentation does not support that the billed services were medically necessary, reasonable, provided or 
billed correctly. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for homecare services provided to the enrollee from January 11, 2021, to January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (15734, 49560, 11006) provided on January 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. Medicare rules say that if a provider reports the
two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. In this case, the CPT Code Manual definition of code 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk". We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 15734 is not supported by the records provided. Our coding reviewer found that the documentation did not include enough details (eg, donor site, neurovascular pedicle preservation) to confirm this procedure was performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 15734 have not been met. Additionally, codes 49560 and 11006 are part of an edit pair with procedure code 44120. Procedure code 44120 is a column one code, and procedure codes 49560 and 11006 are column two codes. Procedure code 44120 has been billed on this date of service, which means that procedure codes 49560 and 11006 are not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (15734, 49560, 11006) provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for the endodontic therapy (D3330) provided on April 13, 2021.
You asked the Plan to reimburse you an additional amount for the dental services. You say that your insurance plan offers up to $1,000 reimbursement for out of pocket dental expenses per year. You say that you do not understand why you were only reimbursed $768 when your bill was for $1,350. The Plan denied your request. The Plan says there is an annual allowance of $1,000 for preventive and comprehensive dental services. The Plan also says that the allowance 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual allowance has been exhausted. The record shows that the Plan paid $129 for dental services performed on February 2, 2021, $103 for dental services performed on March 25, 2021, and $768 for dental services performed on April 13, 2021. $129+$103+$768=$1,000. Therefore, we decided that the Plan does not have to reimburse you an additional amount for the endodontic therapy (D3330) provided on April 13, 2021.