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

We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on August 24, 2021 by an out of network dentist.
You asked the Plan to pay for the dental items. You say that you were advised that your plan would cover dentures up to $2,000. You say that you received a bill for $2,094.50. You also say that you would not have continued with the process had you known you would receive a bill. The Plan denied your request. The Plan
says there is a 50% coinsurance for denture when received out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays the provider.
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 and dentures are listed as covered, there is a 50% coinsurance when you receive them out of network. Additionally, out of network dentists may bill you for any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on August 24, 2021 by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the detailed and extensive oral evaluation
(D0160), incisional biopsy of oral tissue (D7286), cone beam tomography (D0367), and unspecified preventive
service (D1999) provided from May 5, 2021, to June 9, 2021.
You asked the Plan to reimburse you for the dental services. You say that the provider that did the biopsy and
the laboratory were both in network. You say that you were advised this was a split dental/medical claim.
You also say that these services should be covered. The Plan denied your request. The Plan says the services
you received are not listed as covered dental services.
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 dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for
the detailed and extensive oral evaluation (D0160), incisional biopsy of oral tissue (D7286), cone beam
tomography (D0367), and unspecified preventive service (D1999) provided from May 5, 2021, to June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroplasty revision (23474) and shoulder fixation (23700) provided on April 15, 2021.
You asked the Plan to pay for the shoulder arthroplasty revision (23474) and shoulder fixation (23700). You say that the medical records attached support the billing and the claim should be processed for payment. The Plan denied your request. The Plan says the records do not support the services billed.
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 23474 is revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component. The CPT Code Manual definition of code 23700 is manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded).
We asked our coder 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 shoulder arthroplasty revision (23474) and shoulder fixation (23700). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not describe a total shoulder arthroplasty on glenoid component or application of fixation apparatus. Therefore, CPT code 23474 and 23700 cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroplasty revision (23474) and shoulder fixation (23700) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder arthroplasty revision (23474) and shoulder fixation (23700) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prolotherapy injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the medical effectiveness of this injection has not been verified by scientifically-controlled studies.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found prolotherapy is not considered medically necessary because the medical effectiveness has not been verified by scientifically controlled studies. The review has determined that the enrollee does not meet the criteria for this injection. Prolotherapy 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a prolotherapy injection
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Lite test strips.
You asked the Plan to pre-approve the FreeStyle Lite test strips. You say that you would like reconsideration
because the requested test strips are medically necessary. The Plan denied your request. The Plan says the
requested test strips are not the preferred brand.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred
brands and manufacturers as long as the enrollee retains access to all medically necessary items.
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 FreeStyle Lite test strips. Our
reviewer says that no clinical reason was provided regarding why the Plan's preferred diabetic testing supplies
cannot be used. Our physician reviewer found you do not require the requested brand of test strips. The Plan's
preferred brands are adequate and effective.
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 FreeStyle Lite test strips have not been met. Therefore, we decided that the
Plan does not have to pre-approve the FreeStyle Lite test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra.
You asked the Plan to pre-approve Fasenra. You say that Fasenra is medically necessary. The Plan denied your request. The Plan says Fasenra is not covered by the Plan.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Fasenra.
Benefits for Fasenra 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a skilled nursing facility (SNF) stay from
April 1, 2021, to April 10, 2021.
You asked the Plan to waive the coinsurance for the SNF stay. You say that you did not know that the SNF was
an out-of-network provider. The Plan denied your request. The Plan says the proper coinsurance has been
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 30%
coinsurance for Out-of-Network Skilled Nursing Facility per day, days 1 to 100. The total amount allowed was
$2,700.58 and the coinsurance amount was $810.17 ($2,700.58 total amount x 30% coinsurance).
You have been asked to pay a 30% coinsurance for an out-of-network SNF stay. A SNF stay falls within the
Skilled nursing facility (SNF) 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 coinsurance for a
skilled nursing facility (SNF) stay from April 1, 2021, to April 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Cinacalcet billed with code J0604, and related dialysis
procedure services billed with code 90999 for dates of service January 3 - January 30, 2021.
You asked the Plan to pay for codes J0604 and 90999. You say that the claim was inappropriately denied due
to an AX modifier issue for Senispar. The Plan denied your request. The Plan says no separate payment would
be made for J0604 when it is furnished by an ESRD facility to an individual with AKI.
The Plan must follow Medicare rules. Medicare rules say that cinacalcet is an oral drug eligible for
consideration as an ESRD outlier service. ESRD facilities should report revenue code 250 with the drug's
NDC.
We looked at the file and Medicare rules. The records do not show that the codes in dispute were billed along
with the other drugs in rev code 250. Based on this information, we decided that Medicare rules for coverage of
codes J0604 and 90999 have not been met. Therefore, we decided that the Plan does not have to pay for
Cinacalcet billed with code J0604, and related dialysis procedure services billed with code 90999 for dates of
service January 3 - January 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76775) provided on September 7,
2021.
You asked the Plan to pay for ultrasound 76775. You say that you are appealing with records to support this
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because
code 76775 has a procedure-to-procedure (PTP) edit of 1 with code 93976 so is not separately payable without
an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76775
is a column II code to column I code 93976. 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 an abdominal ultrasound (76775) provided on September 7,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300),
electronic connection between wheelchair controller and two or more power seating system motors (E2311),
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial
issue (E2377), and harness for upgrade to expandable controller, including all fasteners, connectors, and
mounting hardware, each (E2313), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the items are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The seat lift does not serve a primary
medical purpose. The upgraded electronics (expandable controller, harness, and electronic connector to 2
power options) are not medically necessary. They are necessary when there is a medical need to control power
options though the joystick. The notes do not show a medical need to control the power options through the
joystick. The power options can be controlled using their own switches. These switches can be made any size
without asking for a separate request. They can be made from any material without asking for a separate
request. All of this can be done without the need to use the joystick to control the power features. Therefore, we
decided that the Plan does not have to pre-approve the power seat elevation system (CPT code E2300),
electronic connection between wheelchair controller and two or more power seating system motors (E2311),
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial
issue (E2377), and harness for upgrade to expandable controller, including all fasteners, connectors, and
mounting hardware, each (E2313), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Itraconazole.
You asked the Plan to pre-approve Itraconazole. You say that continuation of this medication is medically
necessary. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B.
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 pre-approve Itraconazole.
Benefits for Itraconazole 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency
transport (A0427, and ground mileage (A0425) provided on August 15, 2021.
You asked the Plan to pay for the transportation services. You say that the services should be covered. The Plan
denied your request. The Plan says when you enroll in a Medicare-certified hospice program, your hospice
services and your Part A and Part B services related to your terminal prognosis are paid for by Original
Medicare, not your Medicare Advantage plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
You were under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we
decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency
transport (A0427, and ground mileage (A0425) provided on August 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency ambulance transportation on July 30, 2021.
You asked the Plan to waive the copayment for an emergency ambulance transportation. You say that you should not have to pay for this service. The Plan denied your request. The Plan says the proper copayment 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 $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip.
You have been asked to pay a $250 copayment for an emergency ambulance transportation. Emergency ambulance transportation falls within the Medicare-covered 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 an emergency ambulance transportation on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shipping charges for items provided on July 4, 2021.
You asked the Plan to pay for shipping charges. You say that the items at issue were a necessity for your care. 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 sales tax and shipping charges are not separately payable by Medicare. Based on this information, we decided that Medicare rules for coverage of shipping charges have not been met. Therefore, we decided that the Plan does not have to pay for shipping charges for items provided on July 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission for a total shoulder arthroplasty.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan
denied your request. The Plan says this procedure is currently approved as an ambulatory procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case.
Our physician reviewer found the record does not show that at the time of inpatient admission, the admitting
physician reasonable expected that your necessary hospital care (including earlier ED and/or observation care)
would span two midnights. It is not reasonable and necessary to have an inpatient stay for this surgery. Detailed
documentation is not evident regarding a significant past and/or current medical history that would place you at
increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
Therefore, the request for inpatient admission for a total shoulder arthroplasty is not medically reasonable or
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient admission for a total shoulder arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on June 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON office visit. You say that your doctor's office did not follow-up on issuing a referral and if you had waited around for them to do anything you probably wouldn't be able to walk, much less run, right now. The Plan denied your request. The Plan says the services in dispute were not referred by a network provider, were not urgent or emergent, and were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 June 15, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on July
1, 2021.
You asked the Plan to pay for the dental service. You say that you do not understand why this is not covered
under your dental insurance when it states the procedures is covered. The Plan denied your request. The Plan
says unspecified preventive service is not listed as 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 unspecified preventive service is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
unspecified preventive service (D1999) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on July 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the records support the billed code. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the home visit provided on July 13, 2021, by an out-of-network (OON) provider