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

We decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on March 25, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Prolia injection and does not have to 
waive the copayment for the administration provided on January 13, 2021. 
 
You asked the Plan to waive the coinsurance for a Prolia injection and to waive the copayment for the 
administration. You say that you disagree with the charges because you only received an injection. 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 20% oinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $275 copayment for outpatient hospital services.   
 
You received a Prolia injection on January 13, 2021. The total allowed amount is $882.06 and 20% of that is 
$176.41.  
 
You received the administration of a Prolia injection on January 13, 2021, at an outpatient hospital facility. 
Therefore, you are responsible to pay the total allowed amount of $55.66, which is less than the $275 
copayment.  
 
The total amount you owe is: $232.07.  
 
You have been asked to pay the total amount of $232.07 for a Prolia injection and the administration. A Prolia 
injection falls within the Medicare Part B prescription drugs benefit category. The administration falls within 
the outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a 
Prolia injection and does not have to waive the copayment for the administration provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 24, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that your lab performed all the tests that were ordered by the 
referring physician. The Plan denied your request. The Plan says prior authorization was not obtained for these 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab work provided on February 24, 2021 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hernia surgery you had at an outpatient
hospital facility on March 2, 2021.

You asked the Plan to waive the copayment for the hernia surgery. You say that there appears to be a contract
issue with the provider that resulted in you getting charged $1801.27 for this surgery. The Plan denied your
request. The Plan says there was an error on the original bill to you. The Plan says that your claim has been
reprocessed and you only owe a $100 copayment for this surgery.

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 $100
copayment for surgery services at an outpatient hospital facility.

You have been asked to pay a $100 copayment for the hernia surgery. The hernia surgery falls within the
surgery services at an outpatient hospital facility benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for hernia surgery you had at an outpatient hospital facility on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220) and resin-based composite
(D2394) provided on April 21, 2021.

You asked the Plan to pay for the intraoral x-ray (D0220) and resin-based composite (D2394). You say that this
provider has a major role in preventive medical care and treatment. You say that insurance covers a full mouth
set of x-rays. The Plan denied your request. The Plan says the services are not covered 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. Therefore, we decided that the Plan does not have to pay for the
intraoral x-ray (D0220) and resin-based composite (D2394) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) and consultation (D9310) provided on March 8, 2021.

You asked the Plan to pay for the pulp vitality tests and consultation. You say that you were told this visit would be covered under your plan. The Plan denied your request. The Plan says these services are not covered. The Plan also says that there was no mention of pulp vitality tests and consultation during your call with the Plan on March 1, 2021.

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) and consultation (D9310) provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520) provided on June
16, 2020.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says this was billed with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520) provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-operative office visit for a re-evaluation (D0171), 
first intraoral periapical x-ray (D0220), panoramic x-ray (D0330), 2D oral/facial photographic image (D0350), 
diagnostic casts (D0470), modification of removable prosthesis following implant surgery (D5875), and 
occlusion analysis (D9950) provided on November 4, 2020 by an OON provider. 
 
You asked the Plan to pay for the post-operative office visit, first intraoral periapical x-ray, panoramic x-ray, 
2D oral/facial photographic image, diagnostic casts, modification of removable prosthesis, and occlusion 
analysis. You say that you would like to appeal these services. The Plan denied your request. The Plan says 
these services were rendered by an OON provider. The Plan also says that services provided by an OON or 
non-contracted provider are not covered under your benefit program. 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the post-
operative office visit for a re-evaluation (D0171), first intraoral periapical x-ray (D0220), panoramic x-ray 
(D0330), 2D oral/facial photographic image (D0350), diagnostic casts (D0470), modification of removable 
prosthesis following implant surgery (D5875), and occlusion analysis (D9950) provided on November 4, 2020 
by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Aduhelm showed no clinical benefit in the studies population and the enrollee does not meet study inclusion criteria.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Aduhelm. Our reviewer says that the enrollee does not meet the criteria for the requested use of Aduhelm. Our physician reviewer found Aduhelm is Food & Drug Administration (FDA) approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. The documentation is insufficient to support a diagnosis of Alzheimer's disease in the enrollee. The requested use of Aduhelm is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Aduhelm.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an IRF are not met, and the enrollee can safely receive the necessary services in a less intensive 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 documentation does not support the need for a therapy program consisting of at least three hours of therapy per day at least five times per week.
While the enrollee would benefit from physical and occupational therapy, there is no evidence of a need for an intensive therapy program with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on a lack of medical complexity or identified skilled rehab nursing needs. The enrollee's care needs can be easily and safely met at a less intense level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen concentrator because you travel and do not want to carry oxygen tanks with you. The Plan denied your request. The Plan says you have a home oxygen system with portable tanks for your needs within the home.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.

We looked at the file and Medicare rules. The item at issue in this appeal is for use outside of the home.
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.
The record shows you already have portable oxygen tanks. Based on this information, we decided that
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that
the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the toenail debridement procedure you had at an outpatient hospital facility on May 26, 2021.

You asked the Plan to reduce the copayment for the toenail debridement procedure. You say that your copayment for this service should only be $25. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($49.99) is less than your copayment obligation, you are responsible for the full 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 $275 copayment for services in an outpatient hospital facility.

You have been asked to pay a $275 copayment for the toenail debridement procedure. The records show that the facility where you received these services is considered an outpatient hospital facility. That is why the toenail debridement procedure falls within the services in an outpatient hospital facility 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 reduce the copayment for the toenail debridement procedure you had at an outpatient hospital facility on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 13, 2021.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because
these were two separate services. The Plan denied your request. The Plan says CPT code 99223 was billed for
the same date of service by another provider in the same group with the same specialty.

The Plan must follow Medicare rules. Medicare rules say that both Initial Hospital Care (CPT codes 99221 -
99223) and Subsequent Hospital Care codes are "per diem" services and may be reported only once per day by
the same physician or physicians of the same specialty from the same group practice.

We find that CPT code 99223 is not supported in the record. Specifically, the record indicates that CPT code
99223 was billed on the same date of service by a physician in the same group with the same specialty. Based
on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met.
Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on April
13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedic surgeon on April 14, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you did not have x-rays on this date of service. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that this copayment is for the consultation you had with an orthopedic surgeon, not for x-rays.
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 visits with a specialist. You have been asked to pay a $50 copayment for the specialist visit. You were not charged cost sharing for x-rays on this date. 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 office visit you had with an orthopedic surgeon on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided on March 2, 2021. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services with status indicator N are paid under 
the Outpatient Prospective Payment System (OPPS), but their payment is packaged into payment for a 
separately paid service.  We looked at the file and Medicare rules. The code at issue, 99153, has an OPPS status indicator of N, meaning payment for this service is packaged into payment for a separately paid service. Based on this information, we 
decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for sedation services (99153) provided on March 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the records do not support the need for daily therapy on an inpatient basis.

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 physician reviewer
found that the enrollee is at a minimal assist level for sitting and standing up, and contact guard assist for lying
down. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented
skilled therapy needs. The enrollee is ambulating 100 feet and tending to activities of daily living with minimal
supervision. Therefore, the requested SNF services are not medically necessary.

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 a skilled nursing facility (SNF) admission and services.