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

 We decided that the Plan does not have to pay for the continuous intraoperative neuromonitoring rendered on May 6, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0453 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 G0453 is continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure).  We find that CPT code G0453 is not supported in the medical record. Specifically, the documentation does not support the billing of five units of this code. 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 continuous intraoperative neuromonitoring rendered on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on June 2, 2021.  You asked the Plan to pay for codes S1015 and S8301. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 28, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not advised about the covered services of your plan on a certain period of time. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.  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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on August 23, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on August 24, 2021.

You asked the Plan to pay for the consultation. You say that you needed a consult for tooth #12 because you had a root canal done 2 years ago and they think another root may be in the tooth, plus some infection. The Plan denied your request. The Plan says this is not a 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, 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 consultation (D9310) provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genicular nerve block provided on February 25, 2021.  

You asked the Plan to pay for the services provided. You say that the enrollee is not a candidate for a knee replacement. The Plan denied your request. The Plan says the clinical effectiveness in the setting of knee pain has not been demonstrated.  

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 services provided. Our physician reviewer found that the enrollee has chronic left knee pain due to severe osteoarthritis. She is not a candidate for total knee replacement due to her weight. She has tried physical therapy, heat/ice and takes Advil, opiates, Flexeril and topical NSAIDs for pain. The enrollee had a genicular nerve radiofrequency ablation. This is considered an experimental/investigational procedure which is still the subject of clinical trials. It's role in treating knee osteoarthritis is still undefined. Therefore, the procedure was not medically reasonable or 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 the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block provided on February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from August 6, 2021, to August 13, 2021.  

You asked the Plan to waive the copayment for the inpatient care. You say that you live on a tight budget and this cost caught you off guard. The Plan denied your request. The Plan says this claim was processed correctly and in accordance with your contract.  

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 per calendar year for covered services received in a general acute care hospital. You will not pay more than $300 for inpatient hospital covered services in a calendar year.   

You have been asked to pay a $300 deductible for inpatient care. Documentation shows that you had not met this deductible prior to these 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 upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from August 6, 2021, to August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for specialist office visits provided from June 29, 2021, to September 10, 2021.  

You asked the Plan to waive the coinsurance for the specialist office visits. You say that you were not aware of any copayments. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for specialist services.     

You have been asked to pay $25.21 for each visit, which is 20% of the allowed amount for specialist office visits ($126.04 allowed amount x 20% coinsurance = $25.21). The total for three visits is $75.63. Specialist office visits fall 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 coinsurance for specialist office visits provided from June 29, 2021, to September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and topical application of fluoride (D1208) provided on February 15, 2021.

You asked the Plan to pay for the intraoral periapical x-rays and topical application of fluoride. You say that you feel you should not be held responsible for the x-rays. The Plan denied your request. The Plan says these services are not covered.

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 first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and topical application of fluoride (D1208) provided on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 physical therapy (PT) visits (97110).

You asked the Plan to pre-approve 6 additional PT visits. You say that the additional 6 visits are medically necessary. The Plan denied your request. The Plan says the additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation indicates that the enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist beyond what was approved by the plan. The reviewer found that the enrollee has been instructed in a home exercise program. The reviewer found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Therefore, the reviewer found that 6 additional PT visits are not medically reasonable or 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 additional PT visits have not been met. Specifically, the file shows that the enrollee has been instructed in a home exercise program. Therefore, we decided that the Plan does not have to pre-approve 16 physical therapy (PT) visits (97110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on August 26, 2020.

You asked the Plan to pay for the radiology services. You say that you feel that this should be covered due to medical necessity. The Plan denied your request. The Plan says the provider failed to submit this claim within the one year timely filing limit. As such, no payment can be made, and the provider is not allowed to bill you.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the radiology services was not filed until September 29, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the radiology services provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on September 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay more for the periodontal maintenance. You say that you feel the Plan should cover more of this service because you pay so much in premiums and this does not seem to be getting you much coverage. The Plan denied your request. The Plan says you are liable for any cost sharing applied, including deductibles, coinsurances, and copayments according to your 2021 Evidence of Coverage.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a $100 deductible, which $8.01 of this charge applied to. You are also responsible for a 55% coinsurance of the total cost, plus the difference between the billed amount and total cost for the service having been received OON. Therefore, we decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on September 23, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on April 5, 2021.  

You asked the Plan to pay for physician's 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. 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 physician's services provided on April 5, 2021.
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 IRF care is medically reasonable for your condition. The Plan denied your request. The Plan says rules for IRF care have not been met.  

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 you were admitted for shoulder and buttock pain and was treated for a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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.  

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on August 27, 2021.

You asked the Plan to pay for the hearing aids. You say that you want to be reimbursed. The Plan denied your request. The Plan says the hearing aids received were not brand hearing aids and were not received from a network provider.

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. The Plan pays for brand hearing aids only when they are received from the Plan's hearing aid vendor. 

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids purchased were not brand hearing aids and were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve varicose vein sclerotherapy surgery (36471).  You asked the Plan to pre-approve sclerotherapy services. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that the veins in question must be greater than 4 mm in diameter.  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 sclerotherapy services. Our reviewer says that the requested treatment is not medically reasonable and necessary. Our physician reviewer found that the documentation does not meet coverage criteria and does not support the medical necessity of the treatments in question. It is documented that the veins to be treated are spider veins (very small) and reticular (small) veins.  Sclerotherapy of these veins is not covered by the member's plan.  There is no evidence that the veins to be treated meet the size criterion of 4 mm in diameter or larger.  Furthermore, the patient has numerous coexisting conditions that can cause leg pain including a history of foot surgery, bilateral knee replacement, and vertebral disc disease. No edema bilaterally is documented on physical examination. The requested service is not medically reasonable and 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 sclerotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve varicose vein sclerotherapy surgery (36471).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 21, 2021, to June 25, 2021.  

You asked the Plan to waive the copayment for the inpatient care. You say that there was a delay in your skilled nursing facility transfer, and as a result you feel you should only be responsible for one day's cost share. The Plan denied your request. The Plan says they have reviewed their records and found that there was no delay in the authorization process for your transfer, which was not requested until June 23, 2021. The process proceeded as usual within Medicare guidelines. This claim was processed correctly, and the cost-share was assessed in accordance with your contract.  

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 $315 copayment for each of the first seven days of an inpatient stay.  

You have been asked to pay a $1,260 copayment for a four-day inpatient stay ($315 x 4 = $1,260). 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 inpatient hospital admission and services provided from June 21, 2021, to June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on February 12, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  

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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on February 12, 2021, by an out-of-network (OON) provider.