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

 
We decided that the Plan does not have to pay for an office visit (99213) provided on July 27, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 (99213) provided on July 27, 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 a maxillary partial denture (D5211) and a mandibular partial 
denture (D5212) provided by an out-of-network provider. 
 
You asked the Plan to pay for a maxillary partial denture and a mandibular partial denture. You say that you 
would like these dentures. The Plan denied your request. The Plan says you have already exhausted this 
benefit. 
 
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. The Plan covers a maxillary 
partial denture and a mandibular partial denture when the services are provided once every five years.  
 
We looked at the file, and Medicare rules. Evidence was provided that shows that a maxillary partial denture 
was provided on February 14, 2018, and a mandibular partial denture was provided on December 12, 2017. 
Based on this information, we decided that the Plan's rules for coverage of a maxillary partial denture and a 
mandibular partial denture have not been met.  
 Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5211) and a 
mandibular partial denture (D5212) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture services. 
 
You asked the Plan to pre-approve additional acupuncture services. You say that that you have a muscle 
disease and a herniated neck and back disk. You say that acupuncture helps with your pain and circulation. The 
Plan denied your request. The Plan says you have received 27 acupuncture visits in 2021, which exceeds the 
benefit of 20 acupuncture treatment annually. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan?s rules apply 
in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that you have exceeded the maximum 
benefit of twenty acupuncture treatments annually. Therefore, we decided that the Plan does not have to pre-
approve additional acupuncture services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane. You say that the requested treatment is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have 
not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The requested 
drug is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's 
preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion (99601) provided on May 17, 2021.

You asked the Plan to pay for the home infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I and is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion (99601) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incisional biopsy of oral tissue. 
 
You asked the Plan to pre-approve the incisional biopsy of oral tissue. You say that you can't have dentures 
with a wart on your top gum and you don't have the money to pay for the surgical removal. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
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 the 
incisional biopsy of oral tissue.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of 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 not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for robotic assisted laparoscopic 
hysterectomy, bilateral salpingo-oophorectomy and cystoscopy. You were treated for a post-op deep vein 
thrombosis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the bone replacement grafts for tooth #'s 5, 13 and 20.

You asked the Plan to pre-approve the bone replacement grafts. You say that the bone grafts are necessary to have further procedures. You say that the dentist explained that this is necessary due to bone loss that is affecting the health of nearby gums and teeth. The Plan denied your request. The Plan says that the service is not a covered benefit.

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. The Plan covers bone surgery one per quadrant every 3 years. 

We looked at the Evidence of Coverage, the case file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the bone replacement grafts have been met. The Evidence of Coverage clearly says that bone surgery is covered once per quadrant every 3 years. A bone replacement graft is considered bone surgery and the teeth at issue are in different quadrants. Therefore, we decided that the Plan has to pre-approve the bone replacement grafts for tooth #'s 5, 13 and 20. Please note, the bone replacement grafts should be received from an in-network periodontist.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete dentures (D5120 and D5110).

You asked the Plan to pre-approve the complete dentures. You say that the service is medically necessary. The
Plan denied your request. The Plan says you have exhausted the Plan benefit for this 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 requested items or services are not
among those covered under this benefit. Specifically, the records indicate you have already received these
services this year. This means you have exhausted you Plan benefit, and the services are not covered.
Therefore, we decided that the Plan does not have to pre-approve the complete dentures (D5120 and D5110).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on March 2, 2020.

You asked the Plan to waive the copayment for the colonoscopy. You say that this was a screening colonoscopy, so there should be no copayment. The Plan denied your request. The Plan says that you had polyps removed during your colonoscopy, so the outpatient surgery copayment applies.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for screening colonoscopies. 

The Plan says you must pay a $200 copayment for the colonoscopy. We do not agree. We understand that when polyps are removed during a colonoscopy, Original Medicare considers this a diagnostic service for which cost sharing applies. However, Medicare Advantage Plans have an obligation to clearly disclose cost sharing amounts to patients prior to them getting services. In this case, your Evidence of Coverage says that you pay $0 for screening colonoscopies. The medical records from this procedure clearly show that this colonoscopy was performed purely as a screening and not as the result of any symptoms you were having. The Plan's contract does not advise members that if polyps are removed during the course of a screening colonoscopy that the outpatient surgery copayment would apply. The burden is on the Plan to show that they have properly disclosed your cost sharing obligation to you. Based on the language of the contract, it would not be reasonable to expect you to know that an outpatient surgery copayment would apply if you had polyps removed during this screening colonoscopy. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy provided on March 2, 2020.

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: 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 inpatient rehabilitation and ongoing care are 
medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to 
an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level 
of 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee?s nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are 
no acute nursing care needs. Based upon the enrollee's current level of function, he does not require intensive 
therapies consisting of at least three hours of therapy per day at least five days per week with a 
multidisciplinary approach. The enrollee will not make a significant functional progress in a reasonable period 
of time with Dementia. The record does support a need for physical and occupational therapies, but these 
services can be safely provided in an alternate and less intensive setting. The IRF admission 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for electroconvulsive therapy (ECT) services 
you received at an outpatient hospital facility from January 7, 2021, to March 18, 2021. 
 
You asked the Plan to waive the copayments for the ECT services. You say that you are on disability, and you 
were told that all of your copayments would be waived. The Plan denied your request. The Plan says you were 
charged these copayments 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 $150 
copayment for surgery and other services provided at hospital outpatient facilities.  
 
 You have been asked to pay a $150 copayment for the ECT services. The ECT services fall within the surgery 
and other services provided at hospital outpatient facilities 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 electroconvulsive therapy (ECT) services you received at an outpatient hospital 
facility from January 7, 2021, to March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on April 22, 2021. 
 
You asked the Plan to pay for the services. You say that fsfads The Plan denied your request. The Plan says this 
is a bundled service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. 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 the services (70450) provided on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 16, 2021. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 71045 
for the x-ray services is a column II code to column I code 32557.  
 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 the x-
ray services coded 71045 provided on July 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a trigger point injection provided on June 8, 
2021. 
 
You asked the Plan to waive the copayment for a trigger point injection. You say that you were told that once 
you paid the deductible amount you would only owe copayments up to the $1,000 MOOP amount. 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 the MOOP amount for 
2021 is $1,000. Your contract with the Plan also clearly says that you must pay a $150 copayment for 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  
 You received a trigger point injection at an outpatient hospital facility on June 8, 2021. A trigger point injection 
is considered an outpatient surgical procedure. The record shows that you had only paid $485 toward the 
$1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the $150 copayment.  
 
You have been asked to pay a $150 copayment for a trigger point injection. A trigger point injection 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 trigger point injection 
provided on June 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
7, 2021, to May 5, 2021. 
 
You asked the Plan to pay for home health services. You say that nothing is missing on the claim. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that any claim with incomplete, missing, or invalid 
information for all of these elements may be returned as unprocessable. 
 
We looked at the claim submitted, the file and the Medicare rules. In addition to reporting a visit line using the 
G codes as described above, HHAs must report an additional line item with the same revenue code and date of 
service, reporting one of the three Q codes. Based on this information, we decided that Medicare rules for 
completing the claim for home health services have not been met. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from April 7, 2021, to May 5, 2021.