Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee is not able to care for herself. The Plan denied your request. The Plan says the enrollee does not have skilled nursing or therapy needs that need to be provided on a daily basis.  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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and tolerated an oral diet. There were no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a moderate to maximal assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 skilled nursing facility (SNF) services.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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. Our physician reviewer found the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device and supplies (codes E0675 and E0673) provided on March 31, 2021.  You asked the Plan to pay for the pneumatic compression device and supplies. You say that this device is medically necessary for this patient, and it is not considered experimental/investigational The Plan denied your request. The Plan says this specific device is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 are not covered by Medicare. In addition, the rules say that E0673 is only covered when billed with a covered pneumatic compression device.  Because E0675 is not a covered device, this supply is not covered either. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and supplies have not been met Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and supplies (codes E0675 and E0673) provided on March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the $1550 copayment charged for an inpatient admission from April 26, 2021, to May 2, 2021.

You asked the Plan to waive this copayment. You stated that this admission was for Covid-19 and should be covered at no charge. The Plan denied your request. The Plan says the cost sharing was charged based on the services provided.

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 $310 copayment per day for days 1 to 7 of an inpatient stay. It should also be noted that while treatment for Covid-19 was deemed covered by Medicare and the Plan, the contractual copayments were not waived by Medicare.

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 $1550 copayment charged an inpatient hospital stay from April 26, 2021, to
May 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided to the enrollee on June 4, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this testing is not covered by Medicare as a screening.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. There is no indication this testing would affecting the decision-making process for treatment of the enrollee. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on April 15, 2021.  You asked the Plan to pay for the dental service. You say that you were advised that insurance would pay $1,050 per year towards dentures. You say that you do not understand what changed. You also say that you do not know why someone else submitted a claim on your behalf. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service.  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 partial upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5213) provided on April 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 an out-of-network primary care doctor on May 24, 2021.  You asked the Plan to waive the copayment for the out-of-network primary care visit. You say that you have provided all of the documents to have to show that these services should be paid. The Plan denied your request. The Plan says these services were covered and you are only responsible for your $20 copayment.  You are not responsible for the full billed amount.  The Plan says that 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 out-of-network primary care visits.    You have been asked to pay a $20 copayment for the out-of-network primary care 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 an out-of-network primary care doctor on  May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medication, periodontal scaling and root planing, crowns, core buildup and endodontic therapy provided from January 17, 2020, through March 2, 2020.  You asked the Plan to pay for the medication, periodontal scaling and root planing, crowns, core buildup and endodontic therapy. You say that your paperwork lists oral exams, x-rays and cleanings with a $300 benefit. The Plan denied your request. The Plan says the services 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 the medication, periodontal scaling and root planing, crowns, core buildup and endodontic therapy provided from January 17, 2020, through March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided on November 5, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON lab services. You say that the lab services provided are covered by Medicare and should be paid. The Plan denied your request. The Plan says the provider of these services as well as the referring provider are both out-of-network.  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 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 lab services provided on November 5, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for skilled nursing facility services are not met.  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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs are custodial and, as a practical matter, can 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.

You asked the Plan to pre-approve the requested services. You say that this procedure would be less invasive than spinal surgery. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.

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 requested services. Our physician reviewer found that Interspinous process distraction devices are experimental in spinal surgery. More research is needed to show safety and efficacy of the devices. Therefore, the requested device is not considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. You say that you have balance issues and cannot walk or stand well. You say that you prefer to see this provider since they provide balance specific physical therapy. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.  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 physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on May 18, 2021.  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 procedure code G0483 is not supported.  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 G0483 is definitive drug testing, 22 or more drug classes.  We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation shows that only 19 drug classes were tested. 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 pay for the drug testing rendered on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99135 billed for date of service February 8, 2021.  You asked the Plan to pay for procedure code 99135. You say that this claim should be reprocessed. The Plan denied your request. The Plan says this code is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of 'B' are never separately payable.  You billed code 99153.  This code has a status indicator of 'B', so no separate payment is allowable for this code. Therefore, we decided that the Plan does not have to pay for procedure code 99135 billed for date of service February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Shingles vaccine you received on June 17, 2021.  You asked the Plan to pay for the Shingles vaccine. You say that you were told that this shot would be covered. The Plan denied your request. The Plan says the Shingles vaccine is not covered under your medical benefits. The Plan has provided you with a form that you can complete to request payment under your Part D benefits.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine you received on June 17, 2021.       Benefits for the Shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on April 5, 2021.  You asked the Plan to pay for hearing aids. You say that you are 87 years old, and you do not drive. You say that of the Plan's three vendors 2 are 25 miles away and 1 is 29 miles away. You say that you do not own a car and there is no bus service from your home and this provider is about 4 blocks from your home. The Plan denied your request. The Plan says you must utilize your hearing aid benefit with the Plan's hearing provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on August 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON lab services. You say that you believe the ordering provider was a network provider and these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan services are not covered. The Plan says that neither the provider of the lab services nor the ordering provider is a network provider with the Plan.

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 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 lab services provided on August 6, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes A4556 and G0453  You asked the Plan to pay for procedure codes A4556 and G0453. You say that you have provided medical records to justify payment. The Plan denied your request. The Plan says code A4556 is not separately payable and code G0453 has an edit which makes it not separately payable from code 95940 which was also billed on this claim.  All other codes on this claim have been paid.  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 procedure codes G0453 is a column II code to column I code 95940. This claim has not been billed with an appropriate modifier to bypass the edit. In addition, procedure code A4556 has a status indicator of 'P', so no separate payment is allowable for this code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4556 and G0453
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 7, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on August 4, 2020.  You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says must obtain your hearing aids from an in-network provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from an in-network provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not obtained from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 4, 2020.