Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on July 17, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes 99601 and 99602 have a status indicator of I and are not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99601 and 99602 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes 99601 and 99602 have a status indicator of I. This means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pelvic fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 this enrollee 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) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies and accessories provided on October 1, 2020.
You asked the Plan to pay for the CGM supplies and accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order, an itemized shipping invoice, and proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies and accessories provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two retainer crowns (D6750 x2), two core buildups, including any pins when required (D2950 x2), and two pontics (D6240 x2) provided on November 10, 2020.
You asked the Plan to pay for the retainer crowns, core buildups, and pontics. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are excluded from coverage.
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 two retainer crowns (D6750 x2), two core buildups, including any pins when required (D2950 x2), and two pontics (D6240 x2) provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on October 5, 2020.
You asked the Plan to pay for the laboratory test. You say that the test was ordered by the treating physician to help determine the course of treatment. You say that the claim should be processed at the in-network benefit level. The Plan denied your request. The Plan says services should be received from network providers.
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 the laboratory test provided by an out-of-network provider on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on November 16, 2020, to November 20, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $300 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay a $300 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $1,200 ($300 x 4 days = $1,200). The correct copayment has been applied to the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on November 16, 2020, to November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that this provider is in-network, therefore the services should be covered. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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. Although the provider in this case is in-network, the services at issue are not covered under the Plan's supplemental benefit. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve penile prosthesis.
You asked the Plan to pre-approve penile prosthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no documentation of dates or outcomes of required trials.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 penile prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria for placement of a penile prosthesis require failure of all the following forms of therapy, oral erectogenic agents, intracavernosal injections, intraurethral suppositories, and vacuum erection devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of penile prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve penile prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that this service is medically necessary. The Plan denied your request. The Plan says Medicare does not cover experimental services.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is experimental and more research is needed to determine its safety and efficacy. 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work.

You asked the Plan to waive the copayment for the laboratory work. You say that you went in for you annual physical and assumed there would be no charges. You say the copayment should be waived due to COVID-19. 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 $10 copayment for in-Network Medicare-covered laboratory services.

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the laboratory work is considered an additional service to the annual physical exam. The record also shows that member cost share is not waived for laboratory tests.

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 laboratory work.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider.

You asked the Plan to waive the copayment for an MRI. You say that you were never told you would have this additional copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $180 copayment for outpatient diagnostic tests/in-network/advanced imaging services/specialist.

You have been asked to pay a $180 copayment for an MRI. An MRI falls within the outpatient diagnostic tests/in-network/advanced imaging services/specialist 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 an MRI provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider.

You asked the Plan to waive the copayment for lab work. You say that you do not feel like you should be responsible for this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 outpatient diagnostic tests/lab services/outpatient hospital.

You have been asked to pay a $40 copayment for lab work. The correct copayment has been applied to services that were provided. Lab work falls within the outpatient diagnostic tests/lab services/outpatient hospital 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 lab work provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two alveoloplasties in conjunction with extractions, five surgical placements of implant bodies: endosteal implants, radiographic/surgical implant index, bone replacement graft for ridge preservation, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, 11 subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia, and four additional extractions.

You asked the Plan to pay for the alveoloplasties, endosteal implants, radiographic/surgical implant index, bone replacement graft, intravenous moderate (conscious) sedation/analgesia, and four additional extractions. You say that the office verified the enrollee's benefits with the Plan and was advised that you were in network. The Plan denied your request. The Plan says the remaining 4 extractions are not covered because the enrollee's extractions benefit has been exhausted. The Plan also says that the alveoloplasties in conjunction with extractions, surgical placements of implant bodies: endosteal implants, radiographic/surgical implant index, bone replacement graft for ridge preservation, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia are not covered benefits on this enrollee's plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the alveoloplasties in conjunction with extractions, surgical placements of implant bodies: endosteal implants, radiographic/surgical implant index, bone replacement graft for ridge preservation, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia are not among those covered under this benefit. The Plan contract says that extractions are limited to two procedures per calendar year. The record shows that the enrollee received 6 extractions two of which were covered by the Plan, and the enrollee's extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the two alveoloplasties in conjunction with extractions, five surgical placements of implant bodies: endosteal implants, radiographic/surgical implant index, bone replacement graft for ridge preservation, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, 11 subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia, and four additional extractions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81479).
You asked the Plan to pre-approve the genetic testing. You say that the genetic testing is medically necessary. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that C9orf72 genetic testing will be denied as not medically necessary. We looked at the file and Medicare rules. The type of genetic testing requested, C9orf72, is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81479).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 22, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you fell in the Wegmans parking lot and they should be responsible for 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDX epigenetic assay provided on October 19, 2020.
You asked the Plan to pay for the ConfirmMDX epigenetic assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDX testing is covered when the previous negative prostate biopsy must have collected a minimum of 8 tissue cores (but not have received a saturation biopsy of greater than 24 tissue cores) and remaining Formalin-Fixed Paraffin-Embedded (FFPE) tissue from all cores is available for testing. We looked at the file and Medicare rules. Review of the file does not support that the enrollee had a previous negative prostate biopsy. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDX epigenetic assay have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDX epigenetic assay provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation services rendered on September 8, 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 procedure code 99358 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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management service. We find that CPT code 99356 is not supported in the medical record. Specifically, there is no documentation of how much time was spent rendering services to the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation services rendered on September 8, 2020.