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

We decided that the Plan does not have to pay for medical service provided between 10PM and 8AM (99053)
provided on May 15, 2021.
You asked the Plan to pay for overnight medical service 99053. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because
code 99053 is always bundled for payment and is not separately paid.
The Plan must follow Medicare rules. Medicare rules say that code 99053 is always bundled for payment and if
it is covered, payment for it is subsumed by the payment for the services to which it is incident.
We looked at the file and Medicare rules. This code is always bundled for payment and is not separately paid.
Based on this information, we decided that Medicare rules for coverage of overnight medical service 99053
have not been met. Therefore, we decided that the Plan does not have to pay for medical service provided
between 10PM and 8AM (99053) provided on May 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 22 and 27, and custom abutment (D6057) for teeth # 22 and 27.  You asked the Plan to pre-approve the dental services. You say that you have bone loss. You say that as a result, you need to have implants placed to hold your dentures. You also say that dentures will not fit in your mouth otherwise. The Plan denied your request. The Plan says implants are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implants and related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 22 and 27, and custom abutment (D6057) for teeth # 22 and 27.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits and 14 additional
occupational therapy visits.
You asked the Plan to pre-approve the additional physical therapy and occupational therapy visits. You say that
you would like reconsideration because the requested home health services are medically necessary.
The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the
requested home health services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional physical therapy and
occupational therapy visits. Our reviewer says that the records do not show that skilled nursing services are
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or
to establish/perform a maintenance program to maintain the member's condition and/or prevent deterioration.
Our physician reviewer found the records do not show that skilled therapy services are required to effectively
provide treatment, care, and/or services in order to improve the enrollee's level of function, or to
establish/perform a maintenance program to maintain the member's level of function and/or prevent
deterioration.
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 additional physical therapy and occupational therapy visits have not been
met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits and
14 additional occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested
group 3 power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan
says the enrollee does not meet criteria for the requested group 3 power wheelchair and accessories.
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 a group 3 power wheelchair and
accessories. Our reviewer says that the enrollee does not meet criteria for the requested group 3 power
wheelchair and accessories. Our physician reviewer found the enrollee has a mobility deficit that impairs
mobility related activities of daily living (MRADLS) but does not have a Group 3 qualifying diagnosis of a
mobility limitation that is due to a neurological condition, a myopathy, or a congenital skeletal deformity. The
request for Group 3 power wheelchair with accessories is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a group 3 power wheelchair and accessories have not been met. Therefore, we
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve three surgical placements of implant bodies: endosteal implants (D6010 x3), three prefabricated abutments (D6056 x3), and three implant supported porcelain/ceramic crowns (D6065 x3).  You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant supported porcelain/ceramic crowns. You say that the enrollee does not tolerate dentures or bridges. You also say that the enrollee is swallowing her food and getting an upset stomach. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve three surgical placements of implant bodies: endosteal implants (D6010 x3), three prefabricated abutments (D6056 x3), and three implant supported porcelain/ceramic crowns (D6065 x3).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 1,
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 the provider did not bill as required by Medicare coding regulations.

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 76856
is a column II code to column I code 93975. 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 imaging services provided to the enrollee on September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for X-rays provided on September 21, 2021.  You asked the Plan to waive the copayments for X-rays. You say that you paid $15 and are not receiving another bill for $15. 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 $15 copayment per each X-ray.  You received two X-rays on September 21, 2021. Therefore, you are responsible to pay a $15 copayment per each X-ray. The total amount you owe is: $30.    You have been asked to pay the total copayment amount of $30 for X-rays. X-rays fall 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 copayments for X-rays provided on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 19, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records provided that include the
specimen type collected and the billed services cannot be verified. Therefore, we decided that the Plan does not
have to pay for the laboratory services provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary implant/abutment supported fixed denture for edentulous arch (D6114).  You asked the Plan to pre-approve the maxillary implant/abutment supported fixed denture. You say that you believe this procedure would be more cost effective for the Plan instead of having to get a new set of dentures that would fall apart every few years. You also say that you would like this service to be approved for overage. The Plan denied your request. The Plan says this service is not covered by your health plan. The Plan also says that implants are not covered by the Plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary implant/abutment supported fixed denture for edentulous arch (D6114).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot provided on October 21, 2021.
You asked the Plan to waive the coinsurance for the walking boot. You say that you did not use the boot and were unable to return it. The Plan denied your request. The Plan says the correct coinsurance was 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 10% coinsurance for durable medical equipment (DME) items and supplies. You have been asked to pay $15.50, which is 10% of the allowed amount for the walking boot ($155.02 allowed amount x 10% coinsurance = $15.50). The walking boot falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a walking boot provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you were advised to go to an out-of-network provider to receive the care. The Plan denied your request. The Plan says a list of in-network providers was given that can give the enrollee the same type of care.
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 to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the water circulating cold pad with pump (E0218), provided on June 23, 2021, to August 23, 2021.

You asked the Plan to pay for the water circulating cold pad with pump. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the water circulating cold pad with pump (E0218), provided on June 23, 2021, to August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 4, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that services provided were medically necessary for the
enrollee. The Plan denied your request. The Plan says no prior authorization was obtained for the non-
participating providers 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 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 an office visit provided on October 4, 2021, by an
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on
August 30, 2021.
You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the requested service was a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not
been met.
The Plan must follow Medicare rules. Medicare rules say that the 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. Based on this information, we decided that Medicare rules for
coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not
contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the
Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided December 14, 2020.

You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says the service billed is not covered under Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. 

We looked at the file and Medicare rules. The service billed is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation mileage.  You asked the Plan to provide coverage for additional routine transportation mileage. The Plan denied your request. The Plan says the service is a covered benefit, but your request exceeds the 50-mile benefit limit by 61 miles.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, your request exceeds the 50-mile benefit limit by 61 miles. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0801).
You asked the Plan to pre-approve a power scooter (K0801). You say that the requested power scooter is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested power scooter.
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 a power scooter (K0801). Our reviewer
says that the enrollee does not meet criteria for the requested power scooter. Our physician reviewer found the
documentation does indicate that the enrollee has a mobility deficit, but it is not clear that the deficit
significantly impairs mobility related activities of daily living (MRADLs) in the home and this mobility
limitation is not ameliorated by a manual wheelchair. There is no evidence of a trial of a manual wheelchair.
While the enrollee may have the cognition to safely operate the power scooter the documentation does not
support that the POV will significantly improve the enrollee's ability to participate in MRADLs and the
enrollee will use it in the home. The medical progress notes states that the enrollee has mobility limitations
outside of the home. The documentation does not reveal that the requested K0801 is medically necessary per
Local Coverage Determination (LCD):(L33789).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a power scooter (K0801) have not been met. Therefore, we decided that the
Plan does not have to pre-approve a power scooter (K0801).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on October 21,
2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you thought that this would be
fully covered as a preventative service. 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 $350
copayment for outpatient surgery, including services provided at ambulatory surgical centers.
The medical records show that you had polyps removed during a colonoscopy on October 21, 2021. Therefore,
the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay a $350 copayment.
You have been asked to pay a $350 copayment for a colonoscopy. A colonoscopy 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 waive the copayment for a colonoscopy provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pay for the panoramic x-ray. We decided that the Plan does not have to pay for the comprehensive periodontal evaluation.   You asked the Plan to pay for the dental services. You say that you were not aware you were not covered for these services. You also say that this is the first time this has happened. The Plan says that the claim was processed correctly.  We decided that the Plan has to pay for the panoramic x-ray.   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. Specifically, the Evidence of Coverage lists panoramic x-ray as a covered service once per calendar year. The Plan has not provided information to substantiate that this service has been paid for previously. Therefore, we decided that the Plan has to pay for the panoramic x-ray.   We also decided that the Plan does not have to pay for the comprehensive periodontal evaluation.  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 comprehensive periodontal evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on October 21, 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.