Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on June 12, 2020.
You asked the Plan to pay for the services provided. You say that the services were not available from preferred providers. The Plan denied your request. The Plan says there is an appropriate code for the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The file shows that the enrollee received home health physical therapy services, performed by a physical therapist. We looked at the file and the rules. There is a more comprehensive code that describes the services provided.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided May 25, 2021.

You asked the Plan to pay for the psychotherapy services. You say that please see enclosed medical records for review and reconsideration of payment for this claim. The Plan denied your request.

The Plan says there was no documented contact with the attending or primary care physician. There is no referring provider is listed on the claim.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90832) provided May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 10, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is included in the end-stage renal disease (ESRD) prospective payment system (PPS) payment made to the facility and is not separately paid.

The Plan must follow Medicare rules. Medicare rules say that all lab services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD PPS and are not paid separately. 

We looked at the file and Medicare rules. These lab services are included in the ESRD PPS payment made to the dialysis facility and are not paid separately. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).
You asked the Plan to pre-approve the mandibular partial denture. You say that this is a necessary procedure as
the lack of three lower rear teeth creates difficulty when chewing and without the lower denture it would cause
the upper teeth to move and possibly drop. The Plan denied your request. The Plan says this service is not
covered under your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), 5 extractions (D7210), and an interim complete upper denture (D5810).
You asked the Plan to pre-approve the dental services. You say that you need these services The Plan denied your request. The Plan says the requested services are 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 requested dental services are not among those covered under this benefit. Additionally, the record shows that you are not enrolled in the optional supplemental dental rider. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), 5 extractions (D7210), and an interim complete upper denture (D5810).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.
You asked the Plan to pre-approve Entresto. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 and will be brought to the office for administration. 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 Entresto
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on August 26, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 the laboratory work provided on August 26, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology procedure provided on September 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the pathology procedure. You say that you are unable to obtain prior authorization and proactively inform the enrollee of their individual coverage benefits because you do not collect the specimen. The Plan denied your request. The Plan says no prior authorization was obtained.

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. The record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the pathology procedure provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for two (2) physical therapy visits (97162, 97110) provided on August 19, 2021, to August 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to waive the coinsurance for physical therapy visits. You say that you received two bills for your visits, and they were processed as out of network. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 40% coinsurance per day for Medicare-covered physical therapy services when you receive these services from an OON provider.
You have been asked to pay a 40% coinsurance for physical therapy visits. The records show that the provider did not become active with the Plan until September 15, 2021, therefore, the EOC confirms that 40% is the required coinsurance per visit, with an OON provider. On your visit for August 19, 2021, the allowed amount of the claim is $217.16, resulting in a coinsurance obligation of $86.86. On your visit for August 24, 2021, the allowed amount of the claim is $133.31, resulting in a coinsurance obligation of $53.32. Your total cost share is $140.18 ($86.86 + $53.32 = $140.18). Physical therapy visits fall within the outpatient rehabilitation 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 coinsurance for two (2) physical therapy visits (97162, 97110) provided on August 19, 2021, to August 24, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 15,
2021.

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of
service. The Plan denied your request. The Plan says an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

The file shows that CPT code 70450 was billed along with code 70496. We find that CPT code 70450 may be
eligible for payment when billed with this code pair. The claim information does not show that the code at
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay
for the computed tomography (CT) scan provided on August 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for IV infusion therapy (96365) provided on May 10, 2021.

You asked the Plan to waive the copayment for the IV infusion therapy. You say that the services should be covered as you received them before in 2020 and did not have a copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly 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 20% coinsurance for Medicare Part B Prescription drugs. 

You have been asked to pay a 20% coinsurance for IV infusion therapy (the allowed amount is $2944.80 x 20% = $588.96). The record indicates that you received these services in 2020 and were assessed the same 20% coinsurance. IV infusion therapy falls 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 copayment for IV infusion therapy (96365) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110), oral exam (D0150), dental x-rays (D0220, D0230, D0274), and unspecified preventative procedure (D1999) provided on September 17, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says out-of-network dental care is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Supplemental preventative and supplemental comprehensive dental benefits must be obtained from a provider in the Plan's dental vendor network. Services obtained from vendors outside this network are not covered.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110), oral exam (D0150), dental x-rays (D0220, D0230, D0274), and unspecified preventative procedure (D1999) provided on September 17, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).

You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health visit provided on August 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the home health visit. You say that it was impossible to obtain authorization because the enrollee gave incorrect insurance information. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 the home health visit provided on August 17, 2021, by an out-of-network (OON) provider.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.

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: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) (D0383) and consultation (D9310).
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says cone beam CT is not listed as a covered service. The Plan says that consultation is not listed as a covered service either.
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 cone beam CT and consultation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) (D0383) and consultation (D9310).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 12, 2021.
You asked the Plan to pay for the services provided. You say that there is no agreement which indicates the codes are included in the dialysis rate. The Plan denied your request. The Plan says the tests are the responsibility of the dialysis center.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings/sleeves identified with code A6549 and the compression garments with codes S8422 and S8424.

You asked the Plan to pre-approve the compression stockings/sleeves and compression garments. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. 

Codes S8422 and S8424 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pre-approve compression stockings/sleeves identified with code A6549 and the compression garments with codes S8422 and S8424.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing provided on August 23, 2021.
You asked the Plan to pay for the laboratory testing. You say that coronavirus testing is not part of the hospice program. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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. The enrollee was 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 coronavirus testing provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.

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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is still considered experimental. More studies are needed to show safety and efficacy. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).