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

We decided that the Plan does not have to pay for the skilled nursing services provided from November 30, 2019 to December 2, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services provided on these dates are considered custodial, because the enrollee did not need skilled medical care or skilled nursing care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 30, 2019 to December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown. You asked the Plan to pre-approve prefabricated post and core in addition to crown. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered 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. Therefore, we decided that the Plan does not have to pre-approve prefabricated post and core in addition to crown.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 30, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telemedicine specialist office visit provided on April 15, 2020.
You asked the Plan to waive the copayment for the telemedicine specialist office visit. You say that you should not be responsible for the copayment because the call consisted of general questions and lab results. The Plan denied your request. The Plan says you have been charged 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 $40 copayment per specialist visit. You have been asked to pay a $40 copayment for the telemedicine specialist office visit. The telemedicine specialist 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 the telemedicine specialist office visit provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician visit services (CPT 99214) provided to the enrollee
on May 21, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says CPT 99214 was denied as a duplicate due to being billed on the same date of service by another
provider.
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 99214 is "Office or other outpatient visit for the
evaluation and management of an established patient, which requires at least 2 of these 3 key components: A
detailed history; A detailed 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 presenting
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient
and/or family."
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found this
service typically requires only one provider. The supporting documentation that was submitted does not
support CPT code 99214 as being performed for date of service 05/21/2019.
Documentation is required to review the denial of code 99214 for date of service 05/21/2019. The review has
determined that there is no evidence that the denied claim (820192390062777) was separate and distinct, and
not a duplicate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for physician visit services (CPT 99214) provided to the enrollee on May 21, 2019.
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 like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 above. 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 enrollee was admitted to the hospital with general weakness following a fall. The enrollee is in no apparent distress. The enrollee tolerated 15 minutes of gait training and 15 minutes of therapeutic activity. The documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is generally stable and does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While the enrollee may benefit from further physical therapy and occupational therapy, the enrollee does not require an intensive therapy program. The enrollee's care needs can be met at a lower 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 pay for the medical services provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the home visit (99344). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says with limited exceptions, while the member is enrolled in the plan, the member must use network providers to get medical care and 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 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 the medical services provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on January 15, 2020.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve glucose monitor test strips and lancets.
You asked the Plan to pre-approve glucose monitor test strips and lancets. You say that by checking the
enrollee's glucose levels you can have a better idea if treatment needs further adjustment or not. The Plan
denied your request. The Plan says the enrollee is pre-diabetic therefore, criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of glucose monitor test strips have not been met. Therefore, we decided that the Plan does not have to
pre-approve glucose monitor test strips and lancets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the panoramic x-ray, prophylaxis, and bitewings provided on March 16, 2020 by an OON provider.

You asked the Plan to pay more for the panoramic x-ray. You say that you would like the balance due. The Plan denied your request. The Plan says panoramic x-ray is not a covered benefit. The Plan also says that these services were rendered by an out-of-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, panoramic x-ray is not among those covered under this benefit. The contract also clearly states that you are responsible for a 50% coinsurance for bitewings and prophylaxis when they are received by an OON provider. Therefore, we decided that the Plan does not have to pay more for the panoramic x-ray, prophylaxis, and bitewings provided on March 16, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay forophthalmology services provided to the enrollee on March 3, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysservices rendered by nonparticipating providers requires prior authorization.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 Plandoes not haveto pay forophthalmology services provided to the enrollee on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forankle/foot orthosis RT, LT (L1971) provided January 17, 2020.You asked the Plan to pay forthe orthoses. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment.The Plan denied your request. The Plan says the records do not support the billed service. The billed supply code cannot be verified.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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the documentation does not support medical necessity of the requested Ankle-Foot Orthotic (L33686). The provided records do not document weakness or deformity of the foot and ankle with a requirement for stabilization for medical reasons. 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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay forankle/foot orthosis RT, LT (L1971) provided January 17, 2020.
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 you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital for pneumonia
and a knee infection, in the setting of a known abdominal mass. The enrollee has a tracheotomy at baseline,
which was dilated during this hospitalization. The enrollee is not ventilated. The enrollee has been started on
hemodialysis. The enrollee does not require services at the LTACH that are not available at the acute care
hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the
enrollee requires that are not available at the health care setting being offered by the health plan.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) and administration (90471) provided on October 2, 2019.
You asked the Plan to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration. You say that this should be covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) and administration (90471) provided on October 2, 2019.
Benefits for a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 28, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that your copayment should be refunded. You say you tried to see your primary care physician and then urgent care but could not be seen. The Plan denied your request. The Plan says you have been charged 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 $75 copayment for Medicare-covered emergency room visits. You have been asked to pay a $75 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during your emergency room visit.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 emergency room visit provided on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 30 minutes of critical care services (99292) provided on January 12, 2020.
You asked the Plan to pay for the additional critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records do not support that an additional 30 minutes of critical care services were performed in addition to the first 30-74 minutes of a critical care evaluation and management service.
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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT code 99292 is not supported in the record. Specifically, the record indicates that 40 minutes of critical care services were rendered. The record does not show that an additional 30 minutes, beyond the first 74 minutes of critical care services were rendered on this date of service. Based on this information, we decided that Medicare rules for coverage of the additional critical care services have not been met. Therefore, we decided that the Plan does not have to pay for an additional 30 minutes of critical care services (99292) provided on January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90471 and 90750) provided on February 21, 2020.You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because this vaccine was administered in a doctor's office.The Plan denied your request. The Plan says the service in question is not covered under you Medicare Part B Plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay fora shingles vaccine (90471 and 90750) provided on February 21, 2020.Benefits for the shingles vaccine may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on January 21, 2020.
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the $500 benefit is
exhausted with this purchase.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the benefit was exhausted with this purchase.
Therefore, we decided that the Plan does not have to pay for hearing aids provided on January 21, 2020.