Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided on July 30, 2021.  You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges because you were told that the provider accepted your insurance and you paid $20 per visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 copayment for specialist visits and 30% coinsurance for out-of-network Medicare Part B prescription drugs.  You received specialist services on July 30, 2021. Therefore, you are responsible to pay the $20 copayment.   You received a Medicare Part B drug from an out-of-network provider. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $13.26 and 30% of that is $3.98.   The total amount you owe is: $23.98.   You have been asked to pay the total amount of $23.98 for a specialist visit and a Medicare Part B drug. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that you do not agree with the denial. You were able to get the compression stockings several years ago and you need them. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.    Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for local anesthesia (D9215), complicated suture (D7912), a tooth extraction (D7140), and an endosteal implant (D6010) provided by an out-of-network provider on August 3, 2021.  You asked the Plan to pay for local anesthesia, complicated suture, a tooth extraction, and an endosteal implant. You say that you will cancel your dental insurance payments unless you get proper reimbursement. The Plan denied your request. The Plan says the dental services that were provided are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local anesthesia (D9215), complicated suture (D7912), a tooth extraction (D7140), and an endosteal implant (D6010) provided by an out-of-network provider on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve epidural steroid injections.  You asked the Plan to pre-approve the requested services. You say that the enrollee needs the injections. The Plan denied your request. The Plan says the services are not considered medically necessary.  The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical indications.   We looked at the file, and Medicare rules. It is not considered medically reasonable and necessary to perform TFESIs at more than two nerve root levels during the same session. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional epidural steroid injections.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Computed Tomography (CT) of the head or brain (70450) provided on September 19, 2021.  You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 and 70496.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 Computed Tomography (CT) of the head or brain (70450) provided on September 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 19, 2021.  You asked the Plan to pay for the limited oral exam. You say that you would like this covered with a specialist copayment because you were determined to have a medical issue. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee is not expected to improve with LTACH care.

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 physician reviewer found that in this case, the enrollee was admitted from hospice to acute care due to pneumonia and urinary tract infection. The record indicates that the enrollee is bedbound and non-verbal with poor prognosis for improvement. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.

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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nerve conduction studies rendered on June 23, 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 95911 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 95911 is nerve conduction studies; 9-10 studies. We find that CPT code 95911 is not supported in the medical record. Specifically, the documentation does not support that 9-10 nerve conduction studies were performed. 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 nerve conduction studies rendered on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says you do not meet the criteria.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess 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 performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent self-adjustment of insulin dosage based on the blood glucose testing result. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist visits and X-rays provided on February 23, 2021, and October 18, 2021.  You asked the Plan to waive the copayments for specialist visits and X-rays. You say that the receptionist told you that they accepted your insurance and you made a $20 copayment each visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 copayment for specialist visits and a $30 copayment for X-rays.  You received specialist services and an X-ray on February 23, 2021. Therefore, you are responsible to pay a $20 copayment for specialist services and a $30 copayment for the X-ray. The total amount you owe for this visit is: $50.   You received specialist services and an X-ray on October 18, 2021. Therefore, you are responsible to pay a $20 copayment for specialist services and a $30 copayment for the X-ray. The total amount you owe for this visit is: $50.  The total amount you owe is: $100.   You have been asked to pay the total copayment amount of $100 for specialist visits and X-rays. Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for specialist visits and X-rays provided on February 23, 2021, and October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on September 28, 2021, by an OON provider.  You asked the Plan to pay for the laboratory services. You say that the doctor's office never sent the preauthorization form and services were provided. The Plan denied your request. The Plan says the provider and the referring provider are not network provider. There was no pre-authorization for approval.   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 laboratory services provided on September 28, 2021, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection, of diagnostic or therapeutic substance, (62320) provided on August 30, 2021.  You asked the Plan to pay for the injection. You say that this treatment is part of comprehensive pain management program. You say that this service does not have a diagnosis code limitation. You also say that this should be covered. The Plan denied your request. The Plan says the service is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Specifically, the file does not include medical records to support that the service is medically necessary. Therefore, we decided that the Plan does not have to pay for the injection, of diagnostic or therapeutic substance, (62320) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided by an in-network provider on October 11, 2021.  You asked the Plan to pay for a periodic oral evaluation. You say that you think that the Plan should pay for this. The Plan denied your request. The Plan says the benefit limit for D0120 has already been exhausted.  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 two periodic oral evaluations per calendar year.  We looked at the file and Medicare rules. Evidence was provided to show that a periodic oral evaluation was provided on March 15, 2021, and August 11, 2021. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation have already been exhausted. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided by an in-network provider on October 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need therapy. The Plan denied your request. The Plan says that your records show you do not have need for daily skilled nursing nor daily skilled therapy.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services and equipment rendered on May 21, 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 are not covered.  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 35355 is thromboendarterectomy, including patch graft, if performed; iliofemoral. The definition of code 75630 is aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation.  We find that CPT codes 35355 and 75630 are not supported in the medical record. Specifically, there is no documentation of an iliofemoral thromboendarterectomy, including patch graft, to support code 35355. There is no documentation of an abdominal aortography with radiological supervision and interpretation to support code 75630. Based on this information, we decided that Medicare rules for coverage of these services have not been met.   The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  Billed procedure code G0269 (placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure [e.g., angioseal plug, vascular plug]) has a status indicator of B and no separate Medicare payment.  Therefore, we decided that the Plan does not have to pay for the surgical services and equipment rendered on May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve the CGM. The Plan denied your request. The Plan says the coverage criteria are not met.  The Plan follows Medicare rules. Medicare rules say that CGMs are covered when the coverage criteria in the applicable LCD are met.  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 CGM. Our reviewer says that the requested CGM is not medically reasonable and necessary in this case. Our physician reviewer found that that in order for the CGM to be covered the enrollee needs to be taking multiple daily doses of insulin and adjusting the insulin doses based on blood glucose/blood sugar. This is not the case here, so the requested CGM is not covered.  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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 31, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the testing was done for screening.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99053) provided on April 14, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Code 99053 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 99053. 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 (99053) provided on April 14, 2021.