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

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on September 14, 2021.  You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that you contacted the Plan and were advised that the cleaning and x-rays are not deducted from the $1,000 annual maximum. The Plan denied your request. The Plan says your $1,000 benefit maximum was met while processing the claim.  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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on March 10, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on September 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on January 25, 2021.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when the services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   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 billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen for your lung disease (CPT code(s): E1390 and E0431).  

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says you currently suffer from chronic obstructive pulmonary disease (COPD) and your provider is requesting oxygen as part of your treatment. The Plan states after review of the medical records and the Medicare rules it has been determined that, it is not reasonable or medically necessary for you to have an oxygen concentrator.  

The Plan states the medical records from your doctor's visit on July 20, 2021, it states that you have not been using oxygen during the day and there was no documentation submitted with this appeal that shows that you would be compliant with your use of oxygen.  

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 DME. Our physician reviewer found there is no documentation that the requirements listed in the LCD Oxygen and Oxygen Equipment (L33797) for Medicare coverage for the requested oxygen concentrator and portable oxygen have been fully met. In addition to the oxygen saturation measurements which are required for coverage, the LCD states that the request must meet all other applicable Medicare statutory and regulatory requirements. Part of these Medicare statutory and regulatory requirements include "Timely documentation in the beneficiary's medical record showing usage of the item". The supplied records do not document consistent usage of the oxygen equipment; records document selective use of the equipment at night but not during the day.  

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen for your lung disease (CPT code(s): E1390 and E0431).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the type of service requested is not supported because research has not found it to be helpful for the enrollee's condition or for what is causing the enrollee's pain.  

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 pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed.    

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on October 29, 2020, to November 13, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $500 copayment for inpatient hospital care/in-network.      You have been asked to pay a $500 copayment for an inpatient hospital stay. The correct copayment has been applied to the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on October 29, 2020, to November 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on August 26, 2021.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable without a 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 code 71045 is a column II code to column I code 71046. 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 an x-ray (71045) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided July 15, 2020.  You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you don't understand why these services are not covered. The Plan denied your request. The Plan says these services are 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 custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided July 15, 2020.   Your complaint about having issues submitting the claim 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 186.  You asked the Plan to pay for the inpatient hospital services billed with DRG 186. You say that you believe the information submitted supports the services provided. The Plan denied your request. The Plan says that DRG 186 is not supported as the diagnosis of Acute and chronic respiratory failure with hypoxia.  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 secondary diagnosis code, J96.21, defined as Acute and chronic respiratory failure with hypoxia. 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 inpatient hospital services billed with DRG 186. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found based on the criteria not being met for this diagnosis, the acute on chronic respiratory failure with hypoxia billing (DRG 186) was not appropriate for this hospitalization.   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 the inpatient hospital services billed with diagnosis related group (DRG) code 186.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the new patient home visit (99343) provided on August 9, 2021, by an OON provider.  You asked the Plan to pay for the home visit. You say that the medical records provided will show proof of medical necessity. 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 new patient home visit (99343) provided on August 9, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre monitor and supplies (CPT code(s): K0553 and K0554).  You asked the Plan to pre-approve the supplies. You say that you need a better way to track your blood sugar with your new diet that you have been working on with your nutritionist. The Plan denied your request. The Plan says the Medicare rules 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 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 indicates that you are not on insulin.  Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre monitor and supplies (CPT code(s): K0553 and K0554).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the transcatheter stent placement provided on June 29, 2020.  You asked the Plan to reduce the copayment for the transcatheter stent placement. You say that the copayment should be $250 not $275. The Plan denied your request. The Plan says the copayment 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 $0 or $275 copayment for each Medicare-covered outpatient hospital facility visit. $0 copayment for any surgical procedures (i.e., polyp removal) during a colorectal screening. $275 copayment for all other outpatient services including observation and outpatient surgical services not provided in an Ambulatory Surgical Center.   You have been asked to pay a $275 copayment for the transcatheter stent placement. The transcatheter stent placement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 reduce the copayment for the transcatheter stent placement provided on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder monitor test coded 0012M provided on June 24, 2021.  You asked the Plan to pay for the Cxbladder monitor test. 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 [insert custom text from glossary].   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder monitor test coded 0012M provided on June 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound therapy (97035), therapeutic exercises (97110), and physical therapy (PT) evaluation (97161) provided from October 12, 2020, to October 31, 2020 by an out-of-network (OON) provider.  

You asked the Plan to pay for the ultrasound therapy, therapeutic exercises, and PT evaluation. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this patient. The Plan denied your request. The Plan says the OON provider did not contact the Plan to obtain an authorization prior to the 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 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 ultrasound therapy (97035), therapeutic exercises (97110), and physical therapy (PT) evaluation (97161) provided from October 12, 2020, to October 31, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and the requested accessories (CPT code(s): E1007, E2313, E2361, E1012, E0955, E1028, E2377, E2601, E2313, E2311), for the enrollee.  

You asked the Plan to pre-approve the DME. You say that the enrollee is no longer safe with ambulation and now requires a power wheelchair with power tilt and recline. The Plan denied your request. The Plan says Medicare guidance says that a special power wheelchair (Group 3 Power Wheelchair with Multiple Power Options) is medically necessary for individuals that require both power tilt and power recline. The Plan states the notes do not show that the enrollee needs both of these power options, and the upgraded controller, harness and electronics cannot be covered as there is not a medical need to control more than two power options through the joystick.  

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   

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 DME. Our physician reviewer found a Group 3 power wheelchair with multiple power options (power tilt and power recline) is not medically necessary. The documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of daily living (MRADLs) in the home and is not ameliorated by a walker, cane, manual wheelchair due to safety, weakness, and endurance. While the enrollee may have the cognition to be able to safely operate a power wheelchair, the requested K0861 with multiple power options exceeds the enrollee's medical need. The documentation does not support that the enrollee needs is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not reveal that tilt and recline are medically necessary therefore the request for Group 3 power wheelchair with multiple power options is not medically necessary per LCD: Wheelchair Options/Accessories (L33792).  

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and the requested accessories (CPT code(s): E1007, E2313, E2361, E1012, E0955, E1028, E2377, E2601, E2313, E2311), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the evaluation of wheezing (94060) provided on August 18, 2021.  You asked the Plan to waive the copayment for the diagnostic evaluation. You say that you paid a copayment at the time of services and did not expect to owe an additional amount. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $30 copayment for Medicare-covered non-radiological diagnostic services.   You have been asked to pay a $30 copayment for the diagnostic evaluation. An evaluation of wheezing falls within the Medicare-covered non-radiological diagnostic services 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 evaluation of wheezing (94060) provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit and testing (CPT code(s): 99215 and 93005) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says there is an in-network provider that can render the services.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.     The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit and testing (CPT code(s): 99215 and 93005) to be provided by an out-of-network provider.