Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the referral. You say that you would like reconsideration because this provider can help to treat your condition.The Plan denied your request. The Plan says the criteria for out-of-network coverage were not met.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-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laser treatment services provided from October 10, 2018, to November 29, 2018.You asked the Plan to pay for the laser services. The Plan denied your request. The Plan says the service is excluded from your benefits.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Services other than manual manipulation, when performed by a chiropractor, are not covered. Therefore, we decided that the Plan does not have to pay for laser treatment services provided from October 10, 2018, to November 29, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided on October 10, 2019 to November 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for diabetic supplies. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that no prior authorization was obtained. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided on October 10, 2019 to November 1, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm (CPT Code 14301) and adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure (CPT Code 14302) provided to the enrollee on October 8, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Current Procedural Terminology (CPT) code 14301 (1 unit) remains not supported. The submitted medical records do not indicate that adjacent tissue transfer or rearrangement was performed. The submitted medical record indicates that debridement was performed however the documentation does not indicate adjacent tissue transfer was performed. Of note, Current Procedural Terminology (CPT) code 12035 would be a more appropriate code to bill for the services rendered - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm; therefore, the billed code cannot be supported it is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Current Procedural Terminology (CPT) code 14302 (1 unit) remains not supported. The required primary service code (CPT code 14301) is denied in the claim processing system (Reason Code 191); therefore, this service cannot be reimbursed separately. Therefore, we decided that the Plan does not have to pay for Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm (CPT Code 14301) and adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure (CPT Code 14302) provided to the enrollee on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 23, 2019.
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 enrollee's needs would be best met in an LTACH facility. He is likely to require another 25 days of acute care which means he meets Medicare criteria for this coverage. The Plan denied your request. The Plan says the enrollee will not need more than 25 days in the hospital and can just continue to stay in the ICU until he can be discharged.
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 patient is currently undergoing treatment at an ACH for problems with his feeding tube. The enrollee is trach/vent dependent at baseline. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, pulp vitality tests, endodontic therapy, and core buildup, including any pins when required provided on November 5, 2019.
You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, endodontic therapy, and core buildup. You say that you had an infected molar that required immediate treatment. The Plan denied your request. The Plan says these 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 cone beam CT capture and interpretation, pulp vitality tests, endodontic therapy, and core buildup, including any pins when required provided on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 12, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the charges are too high. 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 $225 copayment for ambulance services. You have been asked to pay a $225 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 January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 5, 2020.You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you should not 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 $10 copayment for primary care provider visits. You had an office visit on January 5, 2020. The diagnostic codes submitted on the claim show that services beyond anannual wellness exam were rendered. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit 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 for an office visit provided on January 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a Comprehensive Oral Exam (D0150) provided January 20, 2020.
You asked the Plan to pay for the oral exam. You say that the service should be covered. The Plan denied your request. The Plan says the service is only covered once every 3 years.
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. The Plan covers the oral exam once every 3 years. We looked at the plan contract, the file, and Medicare rules. A Comprehensive Oral Exam (D0150) was already provided on April 22, 2019. This means the service was already provided within the last 3 years. Based on this information, we decided that the Plan's rules for coverage of the oral exam have not been met. Therefore, we decided that the Plan does not have to pay for a Comprehensive Oral Exam (D0150) provided January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 16, 2020.You asked the Plan to pay for the 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this would not improve the enrollee's ability to participate in basic activities.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does have a personal mobility deficit but the documentation does not indicate that it impairs participation in MRADLs as the documentation indicates she has assist for mobility, transfers and self care at her facility. She can use a manual wheelchair in her facility with assist from staff. The documentation reveals that an appropriately sized chair with elevating leg rests will be able to meet the enrollee's needs. While the enrollee may be able to safely operate her PMD the documentation does not reveal that it is medically necessary as there is no indication that the patient's ADLs cannot be effectively met with an appropriately fitted manual wheelchair or that she needs customized seating.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 pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care from November 21, 2019 through November 22, 2019.
You asked the Plan to waive the copayment for observation care. You say that your card only shows a $90 copayment for emergency room. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation care from November 21, 2019 through November 22, 2019. You are asked to pay a $300 copayment for the observation services. 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 observation care from November 21, 2019 through November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown provided on July 25, 2019.You asked the Plan to pay for the retainer crown. You say that you do not have money to pay for this service.The Plan denied your request. The Plan says services received on this date of services, in addition to previous services received throughout 2019, exceed your annual 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 Plan offers a $3,250 annual dental benefit maximum. The contract says that after your annual maximum 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 maximum benefit on September 3, 2019 and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay for the retainer crown provided on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on January 8, 2020. You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are included in a global surgical package. 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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; 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 patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99232 is not supported in the medical record. Specifically, this code was reported within 10 days of the minor surgical procedure coded 36590. The surgical global package includes follow-up
evaluation and management visits during the postoperative period of the surgery that are related to recovery from surgery. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve podiatry services. You say that you were told you could go to any doctor
without a problem. The Plan denied your request. The Plan says there are in-network providers available 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 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-approve
podiatry services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9501) provided on January 24,
2020 through January 30, 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 code S9501 has a status code of I
which is 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 code S9501 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9501 has a status code of I. This means that CPT code S9501 is 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 (S9501) provided on
January 24, 2020 through January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant/abutment supported removable maxillary denture for edentulous arch (D6110) and two semi-precision attachment abutments (D6052x2).You asked the Plan to pre-approve the implant/abutment supported removable maxillary denture and semi-precision attachment abutments. You say that these services are medically necessary.The Plan denied your request. The Plan says this service is not covered under your benefit package.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 an implant/abutment supported removable maxillary denture for edentulous arch (D6110) and two semi-precision attachment abutments (D6052 x2).