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

We decided that the Plan does not have to pay for limited oral exam (D0140) intraoral, periapical first film (D0220) resin-based composite (D2335) provided May 24, 2021.
You asked the Plan to pay for the dental services. You say that you were told that you have $1,000 in dental insurance. Nothing was ever said that you had to go to a certain dentist. You do not understand why you were never notified your dentist was not a provider. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for limited
oral exam (D0140) intraoral, periapical first film (D0220) resin-based composite (D2335) provided May 24, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pressure reducing support surface (E0371).
You asked the Plan to pre-approve the pressure reducing mattress. You say that you require the pressure reducing surface. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.
The Plan follows Medicare rules. Medicare rules say that to meet coverage criteria for a group 2 surface, the enrollee must have stage 3 or 4 pressure ulcer(s). 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 pressure reducing mattress. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days. 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 pressure reducing mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a pressure reducing support surface (E0371).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80299, 80307, 82542, 83789, G0482) rendered by the out-of-network (OON) provider on February 4, 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 laboratory services (80299, 80307, 82542, 83789, G0482) rendered by the out-of-network (OON) provider on February 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Regadenoson injection you received on June 14, 2021.
You asked the Plan to waive the coinsurance for the Regadenoson injection. You say that you were told there was no copayment for a stress test. You said that you should have been told up front that you would have to pay coinsurance for the injection. The Plan denied your request. The Plan says you were not charged a copayment for the stress test itself, but your contract says that you pay this coinsurance for any Part B drugs you receive.
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 Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Regadenoson injection. The Regadenoson injection falls within the Medicare Part B 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 coinsurance for the Regadenoson injection you received on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry with electrocardiographic recording (93229) rendered by the out-of-network (OON) provider on March 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the external mobile cardiovascular telemetry with electrocardiographic recording (93229) rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital admission.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission should be covered. The Plan denied your request. The Plan says the enrollee is not expected to require 2 midnights, therefore inpatient admission is not preapproved.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for a total shoulder arthroplasty.

The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied. The requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the septum surgery you had at an outpatient hospital facility on January 20, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you were never told that there would be a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $300 copayment for the outpatient surgery. 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 septum surgery you had at an outpatient hospital facility on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical cell stimulation, FDA Nutri-Pharmaceutical blend injections, and vasopneumatic device therapy (J1955, J3420) provided March 8, 2021.
You asked the Plan to pay for the electrical cell stimulation, FDA Nutri-Pharmaceutical blend injections, and vasopneumatic device therapy. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are investigational and non-covered.
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 electrical cell stimulation, FDA Nutri-Pharmaceutical blend injections, and vasopneumatic device therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain. The use of vasopneumatic devices may be considered medically necessary for the application of pressure to an extremity for the purpose of reducing edema. The provider notes on the physical examination completed on March 8, 2021, that there is no clubbing, cyanosis, or edema noted to extremities. The subcutaneous injection of FDA Nutri-Pharmaceutical blend in the setting of chronic pain and paresthesia have not been demonstrated in the peer-reviewed literature. 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 electrical cell stimulation, FDA Nutri-Pharmaceutical blend injections, and vasopneumatic device therapy have not been met. Therefore, we decided that the Plan does not have to pay for electrical cell stimulation, FDA Nutri-Pharmaceutical blend injections, and vasopneumatic device therapy (J1955, J3420) provided March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a six month supply of the Ensure drink.
You asked the Plan to pre-approve the nutritional drink. You say that you would like 6 months of Ensure covered. The Plan denied your request. The Plan says the enrollee did not meet coverage criteria in the documentation submitted, more information is required.
The Plan follows Medicare rules. Medicare rules say that Medicare pays for no more than one month's supply of nutrients at any one time. We asked our 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 nutritional drink. Our reviewer says that the request does not meet coverage criteria. Our reviewer found you requested six months of the ensure drink. Medicare only pays for one month.
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 nutritional drink have not been met. Therefore, we decided that the Plan does not have to pre-approve a six month supply of the Ensure drink
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient telehealth office visit (99214) provided May 25, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you should not have to pay $35 for a telephone visit. You are upset and is not paying for a phone call. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $35 copayment for each Medicare covered specialist office visit. You have been asked to pay $35 copayment for the telehealth visit. The telehealth visit falls within the Physician/Practitioner services, including doctor's office visits 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 outpatient telehealth office visit (99214) provided May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and to pay more for the complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on June 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the comprehensive oral evaluation or pay more for the complete series of intraoral x-rays, and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says the comprehensive oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that the cost share was applied correctly per your plan 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on July 31, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and to pay more for the complete series of intraoral x-rays (D0210), and prophylaxis (D1110) provided on June 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 7, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rollator walker with seat attachment.

You asked the Plan to pre-approve the additional rolling walker. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.

The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. 

We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on February 2017 and in May 2019. These rolling walkers are still within the 5-year RUL and the documentation submitted does not show that the walkers are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. This is not based on the information that you had returned the standard walker you received this year. Based on this information, we decided that Medicare rules for coverage of the additional rolling walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a rollator walker with seat attachment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies (procedure code 99072) provided to the enrollee on February 22, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an unbundled service.

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 99072 is "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease."

We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status indicator of "B," which means that this code cannot be paid separately, and payment is always bundled into payment for other services not specified. 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 supplies (procedure code 99072) provided to the enrollee on February 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90832) provided on March 25, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the provided records do not document an attempt to consult with, or a referral from, the enrollee's attending or primary care physician.

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. The provided medical records reflect that the enrollee received psychotherapy services at the request of the attending physician. The Plan's denial rationale has been addressed. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. Therefore, we decided that the Plan has to pay for psychotherapy services (90832) provided on March 25, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81291, 81404, 81405, 81406 81407, 81408, 81439, 81479) provided November 19, 2020.
You asked the Plan to pay for the genetic testing. You say that the genetic testing was medically necessary. The Plan denied your request. The Plan says the service was for screening purposes and is not covered.
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 test at issue in this appeal, genetic cardiovascular risk testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing (81291, 81404, 81405, 81406 81407, 81408, 81439, 81479) provided November 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99397) provided June 28, 2021.

You asked the Plan to pay for the office visit. You say that the visit was medically necessary. The Plan denied your request. The Plan says that your benefit for this service was exhausted.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not elaborate upon which benefit was exhausted or describe what services were provided at this visit. No medical records were submitted to the IRE for review to determine if the service at issue was medically necessary or emergent in nature. The plan has not provided sufficient documentation to the IRE to support this denial. Therefore, we decided that the Plan has to pay for an office visit (99397) provided June 28, 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.