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

We decided that the Plan does not have to pay for gingival irrigation (D4921), and a localized antimicrobial
agent (D4381) provided on April 29, 2021.
You asked the Plan to pay for gingival irrigation, and a localized antimicrobial agent. You say that the services
should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival
irrigation (D4921), and a localized antimicrobial agent (D4381) provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 30, 2021, to April 16, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred to this facility for the same condition and disagree with being charged an additional copayment. 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 $345 copayment, per admission, for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from March 30, 2021, to April 16, 2021. This is considered a new inpatient hospital admission.
Therefore, you are responsible to pay a $345 copayment for days 1-5 (March 30, 2021, to April 3, 2021). The total amount you owe is: $1,725. You have been asked to pay the total copayment amount of $1,725 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from March 30, 2021, to April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and
should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 1, 2020 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the enrollee was referred to this provider. The Plan denied your request. The Plan says the provider did not request prior authorization as required.
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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 1, 2020 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 24, 2021, to June 22, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says these services were not inherently complex or required a skilled registered nurse to 
safely perform. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Ongoing daily skilled services were not required to establish a maintenance program or 
to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical 
matter, could be provided at a lower level of care. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from May 24, 2021, to June 22, 
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections (denosumab) (CPT code J0897), for the enrollee.

You asked the Plan to pre-approve the medication. You say that bisphosphonates are associated with problems with side effects and intolerance. The Plan denied your request. The Plan says you do not reference why bisphosphonates cannot be prescribed for this specific enrollee. The Plan states they were unable to establish the preferred product (zoledronic acid) has been ineffective, not tolerated, or is contraindicated -OR- -provider submitted documentation that the preferred product (zoledronic acid) is not a treatment option.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 medication. Our physician reviewer found the Plan requires a trial of drug zoledronic acid, before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections (denosumab) (CPT code J0897), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing (U0002) provided on May 5, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this code is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing (U0002) provided on May 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies (99072) provided on March 1, 2021, through March 15, 2021.
You asked the Plan to pay for the additional supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this charge is incidental to another 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 record. Specifically, per the Physician Fee Schedule, CPT code 99072 has a status indicator of B. This means that payment for CPT code 99072 is bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies (99072) provided on March 1, 2021, through March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence chair treatment provided from May 26, 2021, to 
June 2, 2021. 
 
You asked the Plan to pay for incontinence chair treatments. You say that this treatment and equipment was 
medically necessary. The Plan denied your request. The Plan says this equipment and treatment are not covered 
by Medicare and you signed an agreement accepting financial responsibility for the treatment. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies and equipment 
are not covered because they are hygienic in nature.  While incontinence supplies and treatment may be 
appropriate in this case, neither the Plan nor Medicare offers coverage of this treatment. Although the FDA has 
approved this treatment and equipment for incontinence, insurance does not cover the cost of these treatments. 
This treatment is considered an out of pocket expense. Therefore, we decided that the Plan does not have to pay 
for incontinence chair treatment provided from May 26, 2021, to June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you cannot do much without help and need a higher level of care. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for myocardial infarction and coronary artery bypass. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial positron emission tomography (PET) for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the notes show stable coronary artery disease and that there are no symptoms.
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 scan. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is asymptomatic and is not on any anti-anginal medications at present. There is no documentation of prior myocardial infarction (MI) or cardiac interventions in the April 2021 visit note, nor is there reason for the PET scan stated, based on either symptoms or specific medical history. No prior exercise testing results are provided. Her blood pressure is well controlled on her current regimen. During the peer to peer, the physician reportedly specified the need for surveillance stress testing every six months. Based on the information provided, there is no clinical indication at this time for a surveillance Rubidium PET scan in the absence of new symptoms or a specific clinical cardiac history (MI, prior revascularization) provided.
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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial positron emission tomography (PET) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on July 19, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you only receive disability benefits and feel these services should be covered. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.
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) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and a complete series of intraoral x-rays (D0210) on December 30, 2019 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1843 L1851).
You asked the Plan to pay for the knee orthosis. You say that the orthosis would help with your condition. The Plan denied your request. The Plan says you have left knee pain due to arthritis, but your records do not demonstrate recent injury or surgery or that instability of your knee was found on physical exam.
The Plan must follow Medicare rules. Medicare rules say that to qualify for coverage of the knee orthoses you must have documentation of a recent injury or surgery to your knee or the notes should show that your knee is unstable on exam. The notes say you have knee pain. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis have not been met.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management services (99217) 
provided June 3, 2021. 
 
You asked the Plan to pay for the discharge day management services. You say that you believe the claim was 
denied in error. Please review all information submitted and reconsider your medical claim for payment. The 
Plan denied your request. The Plan says the records do not support this many/frequency of services. 
 
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 99217 is observation care discharge day management. 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, the qualifying initial (99218-
99220) or subsequent observation care (99224-99226) was not found in the enrollee's claims history. Based on 
this information, we decided that Medicare rules for coverage of the discharge day management services have 
not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day 
management services (99217) provided June 3, 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 June 6, 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 modifier of 1 with code 70496, meaning that this code is payable only if an appropriate modifier is used which was not used on this code.
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 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed on this claim. 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 June 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine (CPT code 90750) and immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (CPT code(s) 90471 and 90472) provided on May 7, 2019, and November 21, 2019.

You asked the Plan to pay for the services. You say that according to the smart summary you received in 2019 it says: "This is one of the preventative services that is covered at no cost under original Medicare, and the plan covers this service at no cost to you. You state since the provider was informed that the reason the claim denied is because they failed to bill this correctly, you do not feel you should now be responsible. The Plan denied your request. The Plan says you do have coverage for the vaccine through your Part D benefits. The Plan states for reimbursement you will need to pay for the service and then mail the reimbursement form back to the address on the form with the proof of your payment and reimbursement will be made to you.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (CPT code 90750) and immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (CPT code(s) 90471 and 90472) provided on May 7, 2019, and November 21, 2019.

Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 4,
2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this decision should be
reversed because this was part of the enrollee's emergency care The Plan denied your request. The Plan says
this service was not denied, but the correct copayment was assessed.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $200 copayment for ambulance services.
The enrollee has been asked to pay a $200 copayment for the ambulance services. This means that the enrollee
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not
have to waive the copayment for ambulance services provided on May 4, 2021.