Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not
require transfer to LTACH.
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. You are
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. There are no services available
at the LTACH that you require that are not available at the health care setting being offered by the health plan.
Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 2 and 4, and a
pontic (D6240) for tooth # 3.
You asked the Plan to pre-approve a fixed bridge. You say that the bridge is necessary to prevent remaining
teeth from shifting. The Plan denied your request. The Plan says fixed bridge is 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 requested fixed bridge is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
retainer crowns (D6750) for teeth # 2 and 4, and a pontic (D6240) for tooth # 3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, the arthrocentesis, and the related services provided on November 3, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit, arthrocentesis, and related services. You say that you did not obtain authorization due to the Coronavirus Pandemic. You say 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 office visit, the arthrocentesis, and the related services provided on November 3, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a supply allowance for a continuous glucose monitor (K0553) provided on April 26, 2021.

You asked the Plan to pay for a supply allowance for a continuous glucose monitor. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested item have not been met.

The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a supply allowance for a continuous glucose monitor. Our reviewer says that the requested item is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has diabetes mellitus and takes Toujeo every day and bolus insulin at meals. The enrollee is checking blood glucose 4 times per day; the enrollee is adjusting the insulin doses according to blood glucose level and the enrollee appears to have close follow-up. Criteria are met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a supply allowance for a continuous glucose monitor have been met. Therefore, we decided that the Plan has to pay for a supply allowance for a continuous glucose monitor (K0553) provided on April 26, 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 the office visit and related services provided on January 28, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for the office visit and related services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says payment is not made to providers who have opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit and related services provided on January 28, 2021, by a provider who has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the brain, (including brain stem); without contrast material (70551) provided on March 29, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $225 copayment for all other diagnostic and nuclear medicine radiological services.
You have been asked to pay a $225 copayment for the diagnostic service provided. 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 magnetic resonance imaging (MRI) of the brain, (including brain stem); without contrast material (70551) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140),
preventive procedure (D1999), surgical extraction (D7210), bone replacement graft for ridge preservation
(D7953), and infiltration of sustained release therapeutic drug (D9613) provided on July 31, 2020 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the problem focused limited oral evaluation, preventive procedure, surgical
extraction, bone replacement graft, and infiltration of sustained release therapeutic drug. You say that these
services were provided due to an emergency, and you were not able to find an in-network dentist at this time
due to the Coronavirus pandemic. The Plan denied your request. The Plan says these services were rendered by
a non-participating 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, the requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation (D0140), preventive procedure (D1999), surgical extraction (D7210), bone
replacement graft for ridge preservation (D7953), and infiltration of sustained release therapeutic drug (D9613)
provided on July 31, 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 dental services provided from November 25, 2020, through May 24, 2021.
You asked the Plan to pay for the dental services. You say that finding a competent doctor to perform the services would be extremely difficult and you should not be forced to find a new dentist because Medicare says so. You say that you have incurred considerable expenses which you have paid for in full and you are requesting reimbursement. The Plan denied your request. The Plan says services performed by a privately contracted provider are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services provided from November 25, 2020, through May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on July 21, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on July 21, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
February 18, 2021, through February 24, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share was applied 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 $325
copayment per day one through five for inpatient hospital care.
You have been asked to pay a $325 copayment per day one through five for the inpatient hospital care. This
service falls within the inpatient hospital care 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 inpatient hospital care provided on February 18, 2021, through February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracorporeal shock wave therapy (28890).

You asked the Plan to pre-approve extracorporeal shock wave therapy. You say that extracorporeal shockwave treatment is medically necessary and appropriate for the enrollee's medical condition. The Plan denied your request. The Plan says the requested service is considered not reasonable and necessary for the treatment of musculoskeletal conditions.

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 extracorporeal shock wave therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve extracorporeal shock wave therapy (28890).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified prosthodontic procedure (D5999).
You asked the Plan to pre-approve the dental item. You say that you need new dentures. You say that the ones
you had done 3 years ago are not fitting properly. You also say that you need the services done because you
have not been using them for over a year. The Plan denied your request. The Plan says the unspecified
prosthodontic procedure is 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 unspecified prosthesis
procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve an unspecified prosthodontic procedure (D5999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded as 99153 provided on March 24, 2021.
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has denied correctly.
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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3. CPT code 99153 was established as a practice expense-only code meaning there is no work component relative value units (RVU) associated with that service. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded as 99153 provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (27495) provided on February 26, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 27495 is "Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur."

We asked our coder 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 use of code 27495 is not supported by the records provided. Our reviewer found that code 27495 is inclusive to the primary service provided and would not be considered a separate procedure. 

We looked at this coder'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 the services (27495) provided on February 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the treatment provided to the enrollee was medically necessary. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that the referring provider is a non-participating provider, and the service was not authorized by the Plan.
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 domiciliary or rest home visit (99336) provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for scaling in presence of generalized moderate or severe
gingival inflammation (D4346) provided on January 27, 2021.
You asked the Plan to hold you harmless for scaling in presence of generalized moderate or severe gingival
inflammation. You say that you told the provider to only do services that would be covered with no out-ofpocket
cost and were told you would not have any additional charges. The Plan denied your request. The Plan
says that you have had the diagnosis of periodontitis and have previously had periodontal root planing and
scaling performed on March 26, 2019. Therefore, the services at issue are not appropriate as you have
periodontal disease and are not covered.
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.
We looked at the file, and Medicare rules. The scaling in presence of generalized moderate or severe gingival
inflammation was provided by a contract provider. The service at issue is normally not covered but could be
covered under some conditions. Therefore, the EOC alone is not adequate notice of non-coverage. The file does
not show that the Plan provided notice that scaling in presence of generalized moderate or severe gingival
inflammation would not be covered. Under Medicare rules, this means the service is considered approved by
the Plan. Therefore, we decided that the Plan has to hold you harmless for scaling in presence of generalized
moderate or severe gingival inflammation (D4346) provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for surgical assistant services provided on May 11, 2021.

You asked the Plan to waive the coinsurance for the surgical assistant services. You say that the provider incorrectly billed under the billing company. You do not think you should have to pay for this mistake. The Plan denied your request. The Plan says that you were charged this out-of-network coinsurance correctly.

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. Specifically, the Plan noted that the billing company is not a contracted provider with the Plan, so the out-of-network cost sharing applies. However, the Plan has not indicated in any way what the actual network status is of the surgical assistant who actually performed the services. In addition, the Plan has failed to indicate if these surgical assistant services were ordered by or arranged by a network provider. Without that key information, we find that the Plan has not substantiated its decision to charge out-of-network coinsurance for these services. Therefore, we decided that the Plan has to waive the coinsurance for surgical assistant services provided on May 11, 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.