Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided on March 18, 2021 by a PT assistant (PTA).
You asked the Plan to pay for the PTA services. You say that this should be paid as it was medically necessary during the COVID-19 pandemic. The Plan denied your request. The Plan says this was billed using the incorrect code.
The Plan must follow Medicare rules. Medicare rules say that PTA services can only be paid when billed by the supervising therapist. They are not payable when billed incident to a physician or NPP's services.
In this case, the services of this PTA are being billed by an NPP who does not meet the qualifications of a therapist. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on March 18, 2021 by a PT assistant (PTA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete lower denture provided on June 16, 2021.
You asked the Plan to pay more for the complete lower denture. You say that you are on a fixed income and are unable to pay. You say that you are appealing the additional funds be made available for the balance on the statement. The Plan denied your request. The Plan says you have maxed the benefit allowed limit of $2500.
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 also have a maximum benefit of $2,500 per calendar year for covered dental services. The Plan paid $2,500 toward the comprehensive oral evaluation provided on June 7, 2021 and the dentures provided on June 16, 2021, which exhausted your benefit. The remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay more for the complete lower denture provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the naturopathic services provided July 26, 2021.
You asked the Plan to pay for the naturopathic services. You say that this service was medically necessary for your condition. The Plan denied your request. The Plan says naturopathic services are not covered under any condition by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the naturopathic services provided July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for anterior instrumentation (22847) provided on March 10, 2021.
You asked the Plan to pay for anterior instrumentation. You say that this is supported in the records. The Plan denied your request. The Plan says this code is not documented.
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 22847 is anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure). We find that CPT code 22847 is not supported in the medical record. Specifically, the submitted records document posterior rather than anterior instrumentation. Based on this information, we decided that Medicare rules for coverage of anterior instrumentation have not been met. Therefore, we decided that the Plan does not have to pay for anterior instrumentation (22847) provided on March 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management (99217), subsequent observation care, per day (99225), and the initial observation care, per day (99220) rendered by the out-of-network (OON) provider from March 30, 2021, through April 1, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the observation care discharge day management (99217), subsequent observation care, per day (99225), and the initial observation care, per day (99220) rendered by the out-of-network (OON) provider from March 30, 2021, through April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6241), retainer crowns (D6751), and post and core (D2954) provided on December 23, 2020, and the intraoral x-ray (D0220) provided on November 30, 2020.
You asked the Plan to pay for the dental services. You say that you did not expect the Plan to pay nothing for these services and are frustrated with the difficulty of finding an in-network dentist. The Plan denied your request. The Plan says pontics, retainer crowns, and post and cores are not covered by your dental benefit, regardless of the network status of the provider. One intraoral x-ray may be covered per year, but you previously had this type of x-ray provided in June 2020, which was paid for by the Plan at that time.
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 does not cover dental services that are not listed in the benefits chart in the contract. The Plan can cover one intraoral x-ray per calendar year. 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 or were provided in a frequency that exceeds what is covered under this benefit. Documentation shows the Plan has paid for a previous intraoral x-ray for you in June 2020. Therefore, we decided that the Plan does not have to pay for the pontic (D6241), retainer crowns (D6751), and post and core (D2954) provided on December 23, 2020, and the intraoral x-ray (D0220) provided on November 30, 2020.
Your complaint about finding an in-network provider for supplemental (non-Medicare covered) benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on May 4, 2021.
You asked the Plan to pay for the periodontal evaluation. You say that you were never told this service would not be covered. The Plan denied your request. The Plan says this service is not covered by your dental 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 the comprehensive periodontal evaluation (D0180) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided April 19, 2021.
You asked the Plan to pay for the diagnostic service. You say that please review documentation supporting multiple providers for date of service as providers were treating the enrollee under a different specialty for different diagnosis. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support medical necessity of the services.
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 find that CPT code 93922 is not supported in the medical record. Specifically, the Plan made multiple attempts to obtain medical records from the provider without success. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided on June 1, 2021.

You asked the Plan to pay for continuous glucose monitor supplies. You say that this is supported in the records. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided on June 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you want to go to the SNF for therapy as you cannot do it at home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled
nursing facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305, 88312, 87481, 87798)
rendered by the out-of-network (OON) provider on June 27, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the laboratory services (88305, 88312, 87481, 87798) rendered by the out-of network
(OON) provider on June 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from October 14, 2020, to October
19, 2020, and billed with DRG (diagnosis related group) 454.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your
request. The Plan says this DRG is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 454, combined anterior and posterior spinal
fusion with complications or comorbidities. 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
inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the
records indicate that the enrollee has a history of Stage III chronic kidney disease. The post-operative course
was uneventful. There was no documentation of postoperative hemorrhage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided from October 14, 2020, to October 19, 2020, and billed with DRG (diagnosis related
group) 454.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the ultrasound procedure provided on July 1, 2021, billed with code 76882.
You asked the Plan to pay for the billed code 76882. You say that this should be paid because the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this was not billed with the required 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 the billed code 76882 is a column II code to column I code 93971. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the ultrasound procedure provided on July 1, 2021, billed with code 76882.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Renflexis.
You asked the Plan to pre-approve Renflexis. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Renflexis. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have to pre-approve Renflexis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the requested item 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 a shower chair.
Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for home health care services provided on July 8, 2021, and
July 12, 2021. We decided that the Plan does not have to pay for home health care services provided on July
15, 2021, and July 19, 2021.
You asked the Plan to pay for home health care services provided on July 8, 2021, and July 12, 2021. You say
that you believed this would be covered. The Plan says that home health services were no longer necessary.
We decided that the Plan has to hold you harmless for home health care services provided on July 8,
2021, and July 12, 2021.
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 provided home health services by a contract provider. The file shows that the Plan did not provide
notice that home health services would not be covered until July 13, 2021. Under Medicare rules, this means
home health services provided on July 8, 2021, and July 12, 2021, were considered approved by the Plan.
Therefore, we decided that the Plan has to hold you harmless for home health care services provided on July 8,
2021, and July 12, 2021.
We also decided that the Plan does not have to pay for home health care services provided on July 15,
2021, and July 19, 2021.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health care services provided on July
15, 2021, and July 19, 2021. Our reviewer says that the home health care services provided on July 15, 2021,
and July 19, 2021, were not medically necessary. Our physician reviewer found the submitted records do not
show that you had documented, ongoing, skilled nursing or therapy needs on these dates.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health care services provided on July 15, 2021, and July 19, 2021, have
not been met. Therefore, we decided that the Plan does not have to pay for home health care services provided
on July 15, 2021, and July 19, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options through their own switches.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is medically necessary for any of the functions described in the Local Coverage Article. 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 an expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the submitted medical records document that the enrollee has 3/5 bilateral upper extremity strength, which is adequate to operate the wheelchair's power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87798, 88305, 88312, 88313) rendered by the out-of-network (OON) provider on June 13, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (87481, 87798, 88305, 88312, 88313) rendered by the out-of-network (OON) provider on June 13, 2020.