Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's nursing, medical management, and rehabilitation needs do not appear to require an interdisciplinary team approach to delivery of rehabilitation care.
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 found to be medically reasonable and necessary for this enrollee. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness, acute kidney injury, and leukocytosis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on March 11, 2021.

You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says routine eye exams must be obtained from a provider in the Plan's vision vendor network.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network. 

We looked at the file and the Plan's rules. The file shows that the eye exam was not obtained from a provider in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power features (K0861) including a power tilt and recline seating system (E1007).
You asked the Plan to pre-approve a Group 3 power wheelchair with a power tilt and recline seating system. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Group 3 power wheelchair with a power tilt and recline seating system. Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, true spasticity, or evidence of being high risk for a pressure ulcer. The enrollee has a qualifying Group 3 diagnosis and has a mobility deficit that impairs mobility-related activities of daily living (MRADLs) but does not meet the criteria for the power tilt and recline. Consequently, the requested Group 3 power wheelchair with multiple power options 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 with a power tilt and recline seating system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power features (K0861) including a power tilt and recline seating system (E1007).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical implant placements (D6010) and abutment supported crowns (D6058) provided on March 16, 2020, and August 4, 2020.
You asked the Plan to pay for the dental services. You say that there was an issue with the billing and these services should be covered. The Plan denied your request. The Plan says these services are not covered by your dental benefit. The Plan also says they confirmed with the provider that the services were provided as billed.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
surgical implant placements (D6010) and abutment supported crowns (D6058) provided on March 16, 2020, and August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of mammography services (77063, 77067) provided on April 9, 2021.

You asked the Plan to pay for additional units of mammography services. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this was previously paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that an addition unit of CPT codes 77063 and 77067 are not supported in the medical record. The medical record only supports one unit each of CPT codes 77063 and 77067, which were previously billed and paid. Based on this information, we decided that Medicare rules for coverage of additional units of mammography services have not been met. Therefore, we decided that the Plan does not have to pay for additional units of mammography services (77063, 77067) provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit with a specialist provided
on June 4, 2021.
You asked the Plan to waive the copayment for a telehealth visit with a specialist. You say that you disagree
with the charges because you were never informed you would owe anything for a telehealth visit 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 $45
copayment for telehealth visits with a specialist.
You have been asked to pay a $45 copayment for a telehealth visit with a specialist. A telehealth visit with a
specialist 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 a telehealth visit with a specialist provided on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve laboratory services to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0675, E0673) provided on August 19, 2020.
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression devices (E0675, E0673) provided on August 19, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for neuromonitoring services (95955, G0453, 95937, 95938) provided on March 12, 2021.

You asked the Plan to pay for neuromonitoring services. You say that this should be considered authorized. The Plan denied your request. The Plan says that this was billed with an incorrect place of service code.

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 has stated that these services were billed with an incorrect place of service code, but a claim form or other documentation was not included in the case file to show the billed place of service. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for neuromonitoring services (95955, G0453, 95937, 95938) provided on March 12, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on May 19, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you feel that you should not be held responsible for the charges for the self-administered drugs. The Plan denied your request. The Plan says self-administered drugs are not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on May 19, 2021.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network
(OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested service.
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 service at issue in this appeal. We found no exception that would require the
Plan to pre-approve the service. Therefore, we decided that the Plan does not have to pre-approve an office
visit to be rendered by the out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 4, 2021, through April 13, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes show the kind of precautions taken and the code should be reprocessed for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from March 4, 2021, through April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on June 15, 2021.

You asked the Plan to pay for the dental services. You say that you were not aware that you would be charged for this examination. You also say that you feel these services should be covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either. The Plan also says that you did not contact them to verify benefits or provider eligibility.

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 limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a gastroenterology nurse practitioner you had on May 21, 2021.
You asked the Plan to waive the copayment for the specialty care visit. You say that you did not request this visit with this nurse practitioner, so you don't think you should have to pay the copayment. 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 $20 copayment for services with a specialist (including nurse practitioners). You have been asked to pay a $20 copayment for the specialty care visit. This copayment applies regardless of the reason for the visit. 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 visit you had with a gastroenterology nurse practitioner you had on May 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Denosumab injection and its administration provided on May 5, 2021.

You asked the Plan to waive the coinsurance for the Denosumab injection and its administration. You say that you say you paid a $35.00 copayment at the time of the visit. You say you cannot afford to pay this amount. 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 for Part B covered chemotherapy drugs. 

You have been asked to pay $187.84 which is 20% of the allowed amount for the Denosumab injection and its administration. The allowed amount is $939.19. ($939.19 x 20% = $187.84).

The Denosumab injection and its administration fall within the "Medicare Part B prescription 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 Denosumab injection and its administration provided on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on May 1, 2021.
You asked the Plan to waive the copayment for the ground mileage and emergency ambulance transportation. You say that you were transferred because the facility thought you were having a stroke, but you explained that your face looked droopy because of the shingles in your ear. You also say that you were not advised that you would be responsible for the bill. The Plan denied your request. The Plan says the copayment is your responsibility.
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 $150 copayment per trip, each way for Ambulance services.
You have been asked to pay a $150 copayment for the ground mileage and emergency ambulance transportation. The ground mileage and emergency ambulance transportation fall within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on May 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 15, 2021.

You asked the Plan to pay for the limited oral evaluation (D0140). You say that the Plan should pay for at least two visits to the dentist a year for teeth problems. The Plan denied your request. The Plan says code D0140 has a frequency limit of one procedure per plan year.

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, you also have a maximum benefit of one limited oral evaluation every plan year. The Plan paid for the limited oral evaluation provided on March 1, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81000) provided on June 11, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized. There were network providers available.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (81000) provided on June 11, 2021.