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

We decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) and the detailed case presentation (D9450) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that this dentist was listed as in network. You also say that you do not know why the services got denied. The Plan denied your request. The Plan says there is a 50% coinsurance for Class 2 Basic Services, including intraoral complete series x-rays. The Plan also says that detailed case presentation is not listed as covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and complete series x-ray is listed as covered, there is a 50% coinsurance for Class 2 Basic Services when received in network. Additionally, the detailed case presentation is not among those covered under this benefit, regardless of the dentist's network status. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) and the detailed case presentation (D9450) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 28, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges and do not know why the Plan is not paying them. 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% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on January 28, 2021. The total allowed amount is $1,931.09 and 20% of that is $386.22.

You have been asked to pay the total coinsurance amount of $386.22 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 2, 2020.
You asked the Plan to pay for the testing services. You say that physicians send specimens for testing. The Plan denied your request. The Plan says the place of service must reflect the location of the enrollee when the specimen was obtained. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The provided claim shows a place of service as an independent laboratory. The records do not indicate the enrollee's specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on February 21, 2021.

You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.

We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status indicator of "B". A status code of B means that this code is always bundled into payment for other services not specificed and no separate payment is made. Based on this information, we decided that Medicare rules for coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service coded 99053 provided on February 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain from sacroilitis. RFA of the lateral sacral branches is considered experimental/investigational in nature due to wide variation in efficacy reported in the medical literature. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walking boot provided on January 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for durable medical equipment. 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 there is no referring provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a walking boot provided on January 5, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541, 87581, 87640, and 87798 provided on June 15, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 87486, 87496, 87498, 87541, 87581, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a nursing Facility and skilled nursing facilities to Part B residents (Place of service code 32). Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87541, 87581, 87640, and 87798 provided on June 15, 2020.
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 you can handle intensive therapy and would not receive the same care in another setting. The Plan denied your request. The Plan says the criteria for an IRF are not met, and your care needs can be met 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 that 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 do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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 the MyoPro device.
You asked the Plan to pre-approve the MyoPro device. You say that you would like reconsideration because you have failed other means of rehabilitation therapy. The Plan denied your request. The Plan says the records provided for review from your treating providers do not document a failure of specific modalities and/or devices used in rehabilitation, or if the MyoPro device is appropriate and is expected to improve function.
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 MyoPro device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for you, improve hemiparetic arm function, or be safe for long erm use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for home health services with a non-certified Medicare provider.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare only covers certified providers.

Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 

The requested provider is not eligible to bill Medicare. The plan did not pre-approve the referral. We found no exception that would require the plan to pre-approve the referral. Therefore, we decided that the Plan does not have to pre-approve a referral for home health services with a non-certified Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided from February 3, 2021 to April 3, 2021.

You asked the Plan to pay for this equipment. You say that this equipment should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network durable
medical equipment.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The 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 durable medical
equipment provided from February 3, 2021, to April 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on November 12, 2020.
You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be reprocessed and paid. 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 infectious agent detection by nucleic acid (U0003) provided on November 12, 2020.
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 you would not get the same level of care in another setting, and your health will deteriorate if you cannot go to an IRF. The Plan denied your request. The Plan says your records show that you do not require physician supervision by a rehab doctor at least three times per week, and you do not have complex rehab needs. You would benefit from continued skilled therapy, but these services can be safely provided 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 that 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 do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology visit received on February 1, 2021.

You asked the Plan to waive the copayment for the ophthalmology visit. You say that you feel this copayment amount should go towards your tetanus shot. The Plan denied your request. The Plan says the claim has been processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each specialist visit. 

You have been asked to pay a $20 copayment for the ophthalmology visit. The ophthalmology visit falls within the physician/practitioner 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 the ophthalmology visit received on February 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a diagnostic colonoscopy provided by a participating provider on July 10, 2020.
You asked the Plan to waive the deductible and copayment for a diagnostic colonoscopy. You say that you do not agree with these charges. You say that this should be covered. The Plan denied your request. The Plan says the correct deductible and coinsurance 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 deductible and a 10% coinsurance for outpatient surgery/in-network.
You have been asked to pay a $300 deductible and a 10% coinsurance of the allowed amount for a diagnostic colonoscopy. The total allowed amount after the deductible is $441.61. Your 10% coinsurance is $44.16 ($441.61 x 10% = $44.61). The total amount you are being asked to pay is $344.61 ($300 deductible + $44.61 = $344.61). A diagnostic colonoscopy falls within the outpatient surgery/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 deductible and copayment for a diagnostic colonoscopy provided by a participating provider on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record show that you have a foot fracture in May of 2021. The records do not show that it is a nonunion fracture. The criteria for overage are not met and the bone growth stimulator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on January 25, 2021.

You asked the Plan to pay for the ambulance services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on January 16, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 25, 2021.