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

We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in a different setting, for example, home with home health, in residential care, or home with close follow-up with the doctor.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems.

Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received from a chiropractor on July 21, 2021.

You asked the Plan to pay for the office visit. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit received from a chiropractor on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit with a physician (99336)
provided on July 15, 2021, by an OON provider.

You asked the Plan to pay for domiciliary or rest home visit with a physician. You say that authorization was
not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for
their patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and
authorization was not obtained prior to the services rendered.

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 domiciliary or rest home visit with a physician
(99336) provided on July 15, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on August 11, 2021.

You asked the Plan to pay for the x-rays. You say that you called to see what could be covered because your provider is out-of-network. You were not told that you could only have a certain type of x-ray. The Plan denied your request. The Plan says complete series of x-rays are 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 complete series of x-rays (D0210) provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the prefabricated abutment (D6056) and abutment
supported crown (D6060) provided on May 3, 2021.
You asked the Plan to reimburse you for the dental services. You say that you are not satisfied with the dental
work that you received. You also say that you would like a full refund of the money you paid. The Plan denied
your request. The Plan says there is a quarterly allowance of $575 for dental services. The Plan also says that
the allowance has 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum allowance has been
exhausted. The record shows that the Plan paid $575 for dental services received on February 20, 2021. The
record shows that the Plan paid $575 for the abutment supported crown received on the date of services in this
case. The Evidence of Coverage says after plan paid benefits for comprehensive dental services, you are
responsible for the remaining costs. Therefore, we decided that the Plan does not have to reimburse you for the
prefabricated abutment (D6056) and abutment supported crown (D6060) provided on May 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services
coded 99601 and 99602 provided from June 3, 2021, to June 15, 2021.

You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed
are not 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.

We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes
have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes.
Medicare uses another code for reporting of, and payment of these services. Based on this information, we
decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not
been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug
administration services coded 99601 and 99602 provided from June 3, 2021, to June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the vacuum erection device (L7900), and taxes provided on
April 13, 2021.

You asked the Plan to pay for the vacuum erection device and taxes. You say that this item is medically
necessary. The Plan denied your request. The Plan says this is not a covered item.

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 the vacuum erection device and taxes have not been met. Therefore, we decided that the Plan does
not have to pay for the vacuum erection device (L7900), and taxes provided on April 13, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on August 15,
2021.

You asked the Plan to waive the copayment for emergency care. You say that this provider was the only one
open. 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 $100
copayment for emergency care.

You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency
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 emergency care provided on
August 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport, (A0998) provided on June 18, 2021.

You asked the Plan to pay for the ambulance service. You say that you fainted at the store. You say that the store staff called for an ambulance without your permission. You say that you did not need medical treatment. You also say that the paramedic advised they would not file a claim. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says since no transport was provided there was no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport, (A0998) provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an ankle foot orthosis provided on July 22, 2021.

You asked the Plan to waive the coinsurance for an ankle foot orthosis. You say that your brace was damaged while you were receiving a colonoscopy and you were told that the provider would pay for a replacement. 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 20% coinsurance for prosthetic devices and related supplies. 

You received an ankle foot orthosis on July 22, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $652.06 and 20% of that is $130.42. 

You have been asked to pay the total coinsurance amount of $130.42 for an ankle foot orthosis. An ankle foot orthosis falls within the prosthetic devices and related 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 coinsurance for an ankle foot orthosis provided on July 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97110) provided on February 6, 2021.

You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.

The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the record shows that this claim was billed by a nurse practitioner and the services were rendered by a physical therapist. There is no evidence that the nurse practitioner was present in the home while these services were being rendered. Therefore, we decided that the Plan does not have to pay for the physical therapy services (97110) provided on February 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) and core buildup procedures (D2950) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the crowns and core buildups. You say that these services are medically necessary. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's network. Out-of-network dental care is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) and core buildup procedures (D2950) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 fillings provided from August 10, 2021, to September 7, 2021.

You asked the Plan to pay for the dental services. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says there is a combined allowance of $2,000 each year. The Plan also says that the allowance has 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the allowance has been exhausted.

The Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay for the 4 fillings provided from August 10, 2021, to September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on May 25, 2021, by an OON
provider.

You asked the Plan to pay for the chiropractic services. You say that the chiropractic services were covered at
your normal chiropractor, but it was closed due to COVID. It was a necessary appointment. The Plan denied
your request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.

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 chiropractic services provided on May 25, 2021,
by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 2, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met.
Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460), topical application of fluoride varnish (D1206), core buildup, including any pins when required (D2950), and endodontic therapy (D3330) provided on July 9, 2021.
You asked the Plan to pay for the pulp vitality tests, topical application of fluoride varnish, core buildup, and endodontic therapy. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.
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 pulp vitality tests (D0460), topical application of fluoride varnish (D1206), core buildup, including any pins when required (D2950), and endodontic therapy (D3330) provided on July 9, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chest wall oscillation system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary due to a diagnosis of bronchiectasis. The Plan denied your request. The Plan says chronic obstructive pulmonary disease (COPD) is an excluded diagnosis.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD), but does not have bronchiectasis by a chest computed tomography (CT) scan. There is no evidence of cystic fibrosis or neuromuscular disease. There is inadequate evidence that the requested system is beneficial in the treatment of COPD.

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve a chest wall oscillation system for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray (73502), and femur x-ray (73552) provided on July 23, 2021.

You asked the Plan to pay for the x-rays. You say that the enrollee was not enrolled in hospice on this date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on July 14, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hip x-ray (73502), and femur x-ray (73552) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the virtual office consultation (99242) provided on August 2,
2021 by an out-of-network (OON) provider located in London, United Kingdom.
You asked the Plan to pay for the office consultation. You say that you were never told that you needed prior
authorization. The Plan denied your request. The Plan says enrollee's must receive their medical services from
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered.
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 virtual office consultation (99242) provided on
August 2, 2021 by an out-of-network (OON) provider located in London, United Kingdom.