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

We decided that the Plan does not have to pay for the treatment of root canal obstruction; non-surgical access
(D3331) provided May 13, 2021.
You asked the Plan to pay for the treatment of root canal obstruction. You say that this was a necessary
preventative measure to avoid infection and more costly procedures down the road. The Plan denied your
request. The Plan says this service is not covered under your 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
treatment of root canal obstruction; non-surgical access (D3331) provided May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge management services (99239) provided on January 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99239 is "Hospital discharge day management; more than 30 minutes". We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that hospital discharge day management services were provided for more than 30 minutes on the date of service in question. 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 the discharge management services (99239) provided on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the Vacuum drainage collection unit and tubing kits (A7048) provided
from November 25, 2019 to August 11, 2020.
You asked the Plan to pay for the Vacuum drainage collection unit and tubing kits (A7048). You say that you
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the
services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the Plan has not provided a valid reason for the denial of payment
for the supplies (A7048) provided from November 25, 2019 to August 11, 2020. The file shows the Plan
authorized the supplies (A7048) for the enrollee from November 21, 2019 through November 20, 2020. The
Plan has not provided any supporting evidence using Medicare guidelines to deny payment for these supplies
(A7048). Therefore, we decided that the Plan has to pay for the Vacuum drainage collection unit and tubing
kits (A7048) provided from November 25, 2019 to August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 infection and peripheral vascular disease of left leg and had below the knee amputation.
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 documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick.
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 self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel Sureclick.
Benefits for these services 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 the denture reline (D5751) provided on May 24, 2021.
You asked the Plan to pay for the dental service. You say that you have no original teeth. You say that you have had top dentures for 30 years. You say that the bottom dentures you received are no good. You say that you had the bottom denture relined. You also say that this service should be covered. The Plan denied your request. The Plan says relines are not a covered dental 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, the denture reline is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture reline (D5751) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220)
provided from April 27, 2021, to April 29, 2021.

You asked the Plan to pay for the limited oral evaluation and periapical x-ray. You say that your tooth broke.
You say that you were in a lot of pain. You say that this was an emergency. You also say that you thought the
services would be covered. The Plan denied your request. The Plan says the limited oral evaluation is not listed
as a covered service. The Plan says that periapical x-ray is not listed as a covered service either.

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 limited oral evaluation and
periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220) provided from April 27, 2021, to
April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bath/shower chair (CPT code E0240), for the enrollee.
You asked the Plan to pre-approve the bath/shower chair. You say that the enrollee needs this chair since they have so many issues with their knees. You state the enrollee suffers from vertigo and they lose their balance, leading the enrollee to fall. The Plan denied your request. The Plan says the bath seat/shower chair is considered a convenience item and is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve the bath/shower chair (CPT code E0240), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the tooth extraction (D7140) provided on June 18, 2021.

You asked the Plan to pay for the extraction. You say that you have a history of cancer and were referred by your primary dental provider to this physician to investigate a suspicious lesion on your gum. The provider excised the lesion, but it was necessary to remove this tooth in order to do so. The Plan denied your request. The Plan says that only in-network dental care is covered by your benefit. This provider is not part of the specified dental network.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the extraction and excision of the lesion by a contract provider. The record indicates that the excision of the lesion was covered by the Plan, but the extraction was denied. Clinical information was not submitted for review, but based on the documentation provided, it appears that the extraction was necessary to proceed with the covered medical excision. There is no information as to why the excision would be covered but not the extraction. The file does not show that the Plan provided notice that the extraction would not be covered. Under Medicare rules, this means the extraction is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the tooth extraction (D7140) provided on June 18, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira Pen Kit.

You asked the Plan to pre-approve Humira Pen Kit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira Pen Kit.

Benefits for Humira Pen Kit 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 18, 2021, to May
20, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that your primary care physician advised
you to go to the emergency room as you were experiencing classic heart attack symptoms. The Plan denied
your request. The Plan says that the services are not medically necessary because the records show the enrollee
did have any findings that would suggest the enrollee had a heart attack.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the emergency department on 5/18/2021 with chest pain. She was
evaluated, had a normal EKG and chest x-ray and her blood pressure, oxygen levels and heart rate were
normal. She also had a normal echocardiogram and cardiac stress test. She was seen in consultation by
Cardiology and discharged home when she was considered medically stable on 5/20/2021. The review has
determined that record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span
two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from May 18, 2021, to May 20, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on
March 15, 2021.

You asked the Plan to pay for CT scan 70450. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450
has a procedure-to-procedure (PTP) edit modifier of 1 with code 70496 meaning this code is not separately
payable without an appropriate modifier.

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, we have confirmed that code CT
scan 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid
as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria
have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT)
scan (70450) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation provided from June 1, 2021, to June 9, 2021.
You asked the Plan to waive the copayment for the outpatient hospital observation. You say that you should not be charged for the services. The Plan denied your request. The Plan says the $737.82 copayment has been removed and the correct cost-sharing amount 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 $200 copayment for outpatient hospital observation services.
You have been asked to pay a $200 copayment for the outpatient hospital observation. The outpatient hospital observation falls within the "Outpatient hospital observation" benefit category. The record shows you were admitted under outpatient observation. 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 outpatient hospital observation provided from June 1, 2021, to June 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) and transitional care management
services (99496) provided on April 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the home visit and transitional care management services. You say that you
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says these
services were rendered by a non-contracted provider, and the services were not referred by a network provider.
The Plan also says that the services were not approved in advance.

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 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 home visit (99349) and transitional care management services (99496) provided on April 12, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation trips. You say that you have additional appointments with your orthopedic doctor. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 48 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the panel testing services provided on February 23, 2021.
You asked the Plan to pay for the testing services. You say that it is a superior test over culture and sensitivity.
The Plan denied your request. The Plan says the testing is unproven.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in
the Medicare rules section, are not covered.
We looked at the file and the rules. There are insufficient medical records to show that the results would be
used to assist in the management and treatment of the enrollee. The testing services were requested for
screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the
Plan does not have to pay for the panel testing services provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement above knee prosthesis with accessories (L5321, L5624, L5631, L5649, L5650, L5651, L5671, L5673, L5968, L5705, L5920, L5950, L5981, L5845, L5856, L8430, L8460, L8480, L5828, L5848) 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 there is no evidence of a change in medical condition.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the enrollee's need as the documentation does not support that the enrollee is a K3 level ambulator. The documentation shows that she used a single point cane for ambulation. Additionally, there is no evidence of a need for a replacement of the alignable system (L5920) on the physician progress reports. 

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 replacement above knee prosthesis with accessories (L5321, L5624, L5631, L5649, L5650, L5651, L5671, L5673, L5968, L5705, L5920, L5950, L5981, L5845, L5856, L8430, L8460, L8480, L5828, L5848) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99153) provided on May 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not
payable.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a
practice expense (PE) only code and is not paid to the physician in the facility setting.
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT
code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to
pay for the anesthesia services (99153) provided on May 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for venipuncture (36415) provided on September 14, 2020.
You asked the Plan to pay for venipuncture. You say that this was medically necessary. The Plan denied your
request. The Plan says that this is incidental to code 80053.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that this is incidental to code 80053 and is not separately payable
because code 36415 has a status indicator of N, meaning it is a bundled service. However, code 36415 has a
status indicator of Q4. The Plan has not provided sufficient information to verify their denial. Therefore, we
decided that the Plan has to pay for venipuncture (36415) provided on September 14, 2020.