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

We decided that the Plan does not have to waive the copayments for podiatry services provided from July 8,
2021, to July 20, 2021.
You asked the Plan to waive the copayments for podiatry services. You say that you have diabetes and should
not owe a copayment for routine podiatry care. 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 $0
copayment for in-network routine podiatry visits if you have a confirmed diabetes diagnosis and a $15
copayment for out-of-network routine podiatry visits if you have a confirmed diabetes diagnosis.
You received podiatry services from an out-of-network provider on July 8, 2021, and July 20, 2021. Therefore,
you are responsible to pay a $15 copayment per each visit. The total amount you owe is: $30.
You have been asked to pay the total copayment amount of $30 for podiatry services. Podiatry services fall within the special supplemental benefits for the chronically ill 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 podiatry services provided from July 8, 2021, to July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on May 4, 2021.
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so is not separately payable without an appropriate 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 CT
scan 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 a computed tomography (CT) scan (70450) provided on May 4, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup (D2950) for tooth #7.
You asked the Plan to pre-approve a crown and core buildup. You say that this service is necessary, and you want to know if it will be covered. The Plan denied your request. The Plan says the requested crown and core buildup are not medically necessary for tooth #7. There is no evidence of decay or other issues that would require a crown.
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 a crown and core buildup when the services are medically necessary and reasonable. 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 a crown and core buildup. Our reviewer says that there is no documentation supporting medical necessity for a replacement crown at this time.
Our physician reviewer found there is no apparent defect of the existing crown on tooth #7; however, the provider noted the crown was 18 years old and required re-cementation several times. A core was placed for tooth #7 within the last 60 months, indicating that the crown had fallen off within that time, likely due to decay, that required a core to restore. It has not been made clear if the crown has fallen off since the core was last replaced. There is no clear marginal decay or documentation of marginal breakdown. As there is no documentation of recent multiple cement failures such that the crown can no longer be retained, and no documentation of marginal integrity failures, there is no medical necessity for a replacement crown at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown and core buildup have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) and core buildup (D2950) for tooth #7.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services provided on August 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the doctor's office failed to send in a pre-authorization form for approval. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 referring provider is not a network provider with the Plan. 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 cytopathology services provided on August 18, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says SNF services are not medically necessary.
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 medically necessary. Our physician reviewer found that from a nursing
perspective, you received oral medications. You had stable vital signs. Your lungs were clear. You were treated
for a chronic deep vein thrombosis. Regarding rehabilitation services, you received physical therapy (PT). You
were at a supervision to contact guard assist level for functional mobility. There are no identifiable skilled
nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing
or therapy services on a daily basis. As a practical matter, you do 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 SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure code 81439) provided to the enrollee on February 5, 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 not medically necessary.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the services at issue in this case that were not supported were not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services (procedure code 81439) provided to the enrollee on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator with settings that could be delivered by bilateral positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for this enrollee with chronic obstructive pulmonary disease (COPD) is not covered.
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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the Life2000 System is not medically necessary, as this system is not a true ventilator. It provides positive pressure oxygen
via nasal canula during activity. There is insufficient evidence of safety and efficacy in the treatment in chronic obstructive pulmonary disease (COPD) or asthma-COPD overlap syndrome (ACOS). Further, nocturnal bilateral positive airway pressure (or a ventilator) is considered not medically necessary because the enrollee does not have CO2 retention. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) therapy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CPAP therapy is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has obstructive sleep apnea (OSA) diagnosed in March of 2020. The notes from the most recent visit on May 6, 2021 indicate that usage issues and attempts to address them were unsuccessful. The enrollee has never met the minimum Medicare usage requirement of at least four hours per day for at least 70 percent of the days. CPAP therapy is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652).
You asked the Plan to pay for a pneumatic compression device. You say that you are requesting continued approval and treatment with her home compression device going forward. The Plan denied your request. The Plan says The review indicates that this was a second authorization request that is being processed as an appeal. Documentation was received with original organizational determination. The PCD was approved on 08/12/2021 for 1 month, 08/12/2021 to 09/11/2021. They are requesting continuation. The submitted documentation including physical exam and measurements does not support that the member has truncal swelling. The review has determined that do not the medical records provided meet the requirements listed in the LCD for Medicare coverage.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652).
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 you do not have anyone to look at you once you are released from the SNF. The Plan denied your request. The Plan says that you no longer require skilled services.
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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral positive airway pressure device (BiPAP).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that the device needs to be replaced.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, there is no documentation that your present device has exceeds its reasonable useful lifetime, or has been lost, stolen, or irreparably broken. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral positive airway pressure device (BiPAP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided August 12, 2021.
You asked the Plan to provide additional payment for the upper and lower partial dentures. You say that you need these services covered. The Plan denied your request. The Plan says you have exhausted your dental benefit for 2021.
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 the upper and lower partial dentures up to the Plan's $2,000 annual maximum for supplemental dental benefits.
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the services you had $983 remaining in your annual dental allowance. This amount was applied to the services and you were responsible for the remaining charges. Therefore, we decided that the Plan does not have to provide additional payment for the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional units of gauze (A6216).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says an over quantity of gauze was ordered.
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 services. Our reviewer says that the requested additional units are not considered medically reasonable and necessary in this case. Our physician reviewer found you have three amputated toes with associated wounds being treated. Gauze (170 units) was ordered for open wound to the toes and nails. You require daily gauze and wrapping replacement of the wounds. It is estimated that you will need enough gauze for 3-4 months of wound treatment. The provided records did not show documentation from your treating physician to clarify and confirm the extent of the wound and gauze needs. Therefore, without sufficient support made, the 170 gauzes will be considered not medically necessary at this time. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional units of gauze (A6216).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laboratory service provided on July 29, 2021.
You asked the Plan to waive the copayment for a laboratory service. You say that you were told that you would not owe a second copayment if you dropped off the second specimen on another day. 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 $10 copayment for each laboratory service. The medical records show that you received a laboratory service on July 29, 2021. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for a laboratory service. A laboratory service falls 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 copayment for a laboratory service provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on July 29, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
The file shows that CPT code 70450 was billed with 70496. We looked at the file and the rules. We find that
CPT code 70450 may be eligible for separate payment when billed with this code pair. The claim does not
show that the code at issue was billed with a modifier suitable for payment. Based on this information, we
decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan
does not have to pay for the computed tomography (CT) scan provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services provided from May 29, 2021, to August 31, 2021.
You asked the Plan to waive the coinsurance for the dialysis services. You say that it was your understanding that dialysis would be paid through your insurance. You say you are unable to pay for dialysis. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 per treatment for outpatient dialysis treatments.
You have been asked to pay $2,701.81 for the dialysis services. The dialysis services fall within the "Services to treat kidney disease" benefit category. See chart below.
Dates of Service (DOS)
Service
Allowed Amount
Coinsurance
Number of DOS
Member Liability
May 29, 2021
Dialysis
$436.77
20%
1
$87.35
June 1, 2021, to June 29, 2021
Dialysis
$436.77
20%
13
$1,135.55
July 1, 2021, to July 31, 2021
Dialysis
$436.77
20%
14
$1,222.96
August 28, 2021, to August 31, 2021
Dialysis
$436.77
20%
2
$174.70
August 26, 2021
Dialysis
$436.77
20%
1
$81.25 - This is less than the standard coinsurance amount.
August 3, 2021, to August 24, 2021
Dialysis
$436.77
20%
9
$0 - This is less than the standard coinsurance amount.
Total
$2,701.81
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 dialysis services provided from May 29, 2021, to August 31, 2021.