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

We decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation (D7953 x 2) provided on June 28, 2021.

You asked the Plan to pay for the dental services. You say that the 2 surgical procedures should be covered under your medical benefit. The Plan denied your request. The Plan says the services you received are routine dental in nature. The Plan also says that routine dental services are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement grafts for ridge preservation (D7953 x 2) provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services provided on August 11, 2021, billed with code 99100.
You asked the Plan to pay for the services as billed. You say that this claim should be paid due to medical necessity. The Plan denied your request. The Plan says it was decided that payment should be made for the code 00732, but no separate payment is allowed for 99100.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99100 has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this service is always bundled in payment for other services. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia services provided on August 11, 2021, billed with code 99100.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 24, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network card.
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 out of network physician services provided to the enrollee on August 24, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from December 11, 2020 to December 31, 2020.

You asked the Plan to pay for the home health services. 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 as billed.

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's only reason for the denial of payment for the home health services is due to an invalid first billable code (S9122). However, the Plan provided no evidence per Medicare guidelines that this code is not payable as submitted. Furthermore, the Plan denied the entire claim for payment with no explanation as to why the other services provided were not paid. It is the Plan's responsibility to provide evidence supporting their reasoning for the denial of payment per Medicare guidelines. Therefore, we decided that the Plan has to pay for the home health services provided from December 11, 2020 to December 31, 2020.

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on May 25, 2021.

You asked the Plan to pay for durable medical equipment. The Plan denied your request. The Plan says that 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 durable medical equipment provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 19, 2021, to August 26, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you believe you received poor and negligent care. You believe you got an infection in the hospital, so you should not have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $175 copayment per day for days 1-6 for inpatient hospital care. 

Records show that you were in the hospital for seven days. You were charged a $175 copayment per day for days 1-6, for a total of $1050. This copayment applies per admission, regardless of the reason for the admission. You have been asked to pay a $175 copayment per day for days 1-6 for the inpatient hospital services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 19, 2021, to August 26, 2021.

The Qualified Independent Contractor read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from May 1, 2021, to May 11, 2021, and from May 13, 2021, to May 31, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that the social worker told you that there would be no charge for this. You said that the enrollee fell, which resulted in him having to return to the SNF and the copayment applying. The Plan denied your request. The Plan says this copayment was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20, and a $125 copayment per day for days 21-40 for skilled nursing facility services. 

Records show that the enrollee was in the SNF from April 25, 2021, to May 11, 2021, for a total of 16 days. He was not charged a copayment for this stay. He then returned to the SNF from May 13, 2021-May 31, 2021, for a total of an additional 18 days. He was not charged a copayment for the remaining 4 days of the 20 that is copayment-free. For the remaining 14 days, the enrollee is responsible for a $125 copayment per day, for a total of $1750. However, the Plan has only charged 12 days' worth of this copayment, so he is only being billed $1500 for the SNF stay. This copayment applies regardless of the reason for the stay or your satisfaction with the services received. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from May 1, 2021, to May 11, 2021, and from May 13, 2021, to May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided by an out-of-network provider on July 12, 2021.

You asked the Plan to pay for the eye exam and refraction. You say that you were denied payment for your yearly eye exam. The Plan denied your request. The Plan says this service is not covered out-of- network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a network provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and refraction have not been met. Specifically, the services were not received from a network provider. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction provided by an out-of-network provider on July 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit limit has been exceeded.
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 24 one-way 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 pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction and an evaluation to be performed by an oral surgeon.

You asked the Plan to pre-approve a dental extraction and an evaluation to be performed by an oral surgeon. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says covered services must be performed by a participating general dentist. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a dental extraction and an evaluation to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental extraction and an evaluation to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided by a contracted provider on August 31, 2021.

You asked the Plan to pay for an unspecified preventive procedure. You say that you grind your teeth while sleeping and a filling had fallen out of your tooth. The Plan denied your request. The Plan says the services provided 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 pay for an unspecified preventive procedure (D1999) provided by a contracted provider on August 31, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (S9338) provided to the enrollee on March 5, 2021.
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 this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code S9338 is "Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem." We find that HCPCS code S9338 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy services (S9338) provided to the enrollee on March 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on May 6, 2021.
You asked the Plan to pay for laboratory 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 laboratory services provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unattended electrical stimulation (G0283) and vitamin B injection (J3420) provided during a Sanexas device treatment on July 13, 2021.

You asked the Plan to pay for the services rendered. 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 therapy services are only covered when provided by certified therapists. In addition, compounded drugs must be billed using the NOC code J7999. 

G0283 is a therapy service and was billed by a provider who is not a therapist. In addition, the use of vitamin B was in a prefilled syringe with compounded drugs. This should be billed with one unit of J7999.

Therefore, we decided that the Plan does not have to pay for the unattended electrical stimulation (G0283) and vitamin B injection (J3420) provided during a Sanexas device treatment on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care services provided on December 12, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing care services. You say that the services were 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the nursing care services provided on December 12, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lenses and tint provided on September 10, 2021.

You asked the Plan to pay for the polycarbonate lenses and tint. You say that you order glasses and paid $46. You say that you don't wear glasses every year and if you want polycarbonate it should be covered. The Plan denied your request. The Plan says lens enhancement services are not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover lens enhancements. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the polycarbonate lenses and tint have not been met. Specifically, lens enhancements are not covered. Therefore, we decided that the Plan does not have to pay for the polycarbonate lenses and tint provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided August 5, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the complete upper and lower denture. You say that your dentures were lost during an ambulance trip and you required a new set. The Plan denied your request. The Plan says dental services are not covered when provided OON.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the complete upper and lower denture when the services are provided in-network. 

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the complete upper and lower denture have not been met. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

You will be limited by her weight-bearing status. Your care needs can be met at a lower level of care (ex. SNF/SAR). 

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 admission to an inpatient rehabilitation facility (IRF).