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

We decided that the Plan does not have to pay for physical therapy services provided from February 3, 2020, through February 24, 2020.
You asked the Plan to pay for physical therapy services. You say that your office policy is to send all claims on the date they are produced, and the printed date is within the deadline. You say that the claims should be promptly processed and paid for the services rendered. The Plan denied your request. The Plan says the claim was filed beyond the applicable timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for physical therapy services was not filed until February 25, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from February 3, 2020, through February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from May 11, 2020, to May 15,
2020.

You asked the Plan to pay for the inpatient care. You say that the services rendered to the enrollee were
medically necessary. The Plan denied your request. The Plan says that you have 180 days from the date of
service to file a claim. The Plan says that the claim was not received until after the deadline for timely filing.
The Plan also says that good cause was not presented as to why the claim was filed untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the inpatient care was filed January 7, 2021. This means that less than one
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan
has to pay for the inpatient hospital services provided from May 11, 2020, to May 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the otolaryngologist office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the otolaryngologist office visit. You say that you have already seen the in-network provider for a different issue and do not want to return. The Plan denied your request. The Plan says the provider is 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the otolaryngologist office visit to be provided 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 removal of an impacted tooth (D7240) provided on May 14, 2021.

You asked the Plan to pay for the removal of an impacted tooth. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the removal of an impacted tooth (D7240) provided on May 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prochlorperazine 10mg tablets.
You asked the Plan to pre-approve the prochlorperazine tablets. You say that this is needed to treat the enrollee's sever nausea. The Plan denied your request. The Plan says this oral 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 prochlorperazine 10mg tablets.
Benefits for the prochlorperazine tablets 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 the scaling in presence of generalized moderate or severe gingival inflammation (D4346), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on May 27, 2021, and May 28, 2021.

You asked the Plan to pay for the scaling, comprehensive oral evaluation, and complete series of intraoral x-rays. You say that you have paid in full for these denied services which is a financial hardship for you. The Plan denied your request. The Plan says the scaling is not a covered benefit under your dental plan. The Plan also says that the comprehensive oral evaluation and complete series of intraoral x-rays exceed the frequency limitations in 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, scaling in presence of generalized moderate or severe gingival inflammation (D4346) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on February 7, 2020 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on May 27, 2021, and May 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on May 17, 2021.
You asked the Plan to pay for the services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this is an unbundled 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 76857 has a bundled relationship with code 76775 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on May 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from January 1, 2021, to January 15, 2021.
You asked the Plan to pay for home health services. You say that these services do not require authorization. The Plan denied your request. The Plan says these services were non-covered custodial care.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health services provided from January 1, 2021, to January 15, 2021.
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 it is felt that IRF care is needed due to this enrollee's medical conditions. The Plan denied your request. The Plan says there is no need for an intensive therapy program, and it is not likely the enrollee will be able to participate in three hours of daily therapy.
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 the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for axillary abscess and was discharged home with home health services on 9/17/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pay more for the root canal, crown and core buildup provided on
May 26, 2020.
You asked the Plan to pay more for the root canal, crown and core buildup. You say that the dentist informed
you they were trying to get the Plan the necessary information to process the claim and to ignore the bills. You
say that you were told many times the claim was being handled and the claim should be resolved before
receiving another bill from the dentist. The Plan denied your request. The Plan says the claim reprocessed to
pay $378 for the root canal which met your maximum amount for dental services for the year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit
of $750 per year for covered dental services. The Plan paid $378 toward the root canal to meet your maximum
benefit of $750. The remaining charges are your responsibility. Therefore, we decided that the Plan does not
have to pay more for the root canal, crown and core buildup provided on May 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left total knee arthroplasty.

You asked the Plan to pre-approve left total knee arthroplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that total knee arthroplasty is only covered for certain indications. 

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 left total knee arthroplasty. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee has bone on bone and severe arthritic changes. The documentation shows that the enrollee has tried rest, activity modification, and nonsteroidal anti-inflammatory medications in the past. There is no documentation of three months of conservative measures to include recent physical therapy. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of left total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve left total knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).

You asked the Plan to pre-approve a pneumatic compression device and sleeves. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that criteria for coverage is not met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, heart.

You asked the Plan to pre-approve computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571). You say that this service is to further assess the risk of coronary artery disease and guide decision making of statin dose. The Plan denied your request. The Plan says imaging to measure the amount of calcium deposits in the blood vessels that supply blood to your heart muscle is not a covered service.

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, computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571), is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve computed tomography, heart.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Minuteman procedure (CPT code(s): 22612 and C1713).
You asked the Plan to pre-approve the Minuteman procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says because there is not support for the use of the Minuteman procedure in the literature, this procedure is considered experimental.
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 Minuteman procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Minuteman procedure is experimental for back pain. More research is needed to show safety and efficacy of the device used in this spine surgery. 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 Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Minuteman procedure (CPT code(s): 22612 and C1713).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on June 8, 2021.

You asked the Plan to pay for the resin-based composite. You say that you were not aware that your dental coverage did not include emergency services that were rendered while you were on vacation. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you were not enrolled in the supplemental dental coverage at the time this service was received.

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 resin-based composite (D2391) provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on September 17, 2020 by an OON
provider.

You asked the Plan to pay for the wound care. 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. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the wound care provided on September 17, 2020 by an OON
provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for biopsies provided on February 26, 2021, and March 26, 2021.

You asked the Plan to waive the copayment for biopsies. You say that you were told that you would only owe a $90 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received a biopsy on February 26, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $250 copayment.

You received a biopsy on March 26, 2021, at an outpatient hospital facility. Therefore, you are responsible to pay the $250 copayment. 

The total amount you owe is: $500. 

You have been asked to pay the total copayment amount of $500 for biopsies. Biopsies fall within the outpatient surgery and other medical 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 biopsies provided on February 26, 2021, and March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 3) provided on May 8, 2021.

You asked the Plan to pay for the dental services. You say that this was your first dental appointment in 3 years. You say that you were not aware that the plan only covered 1 x-ray until after you received the services. You also say that you feel an exception for these services should be made. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 periapical x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 3) provided on May 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-home infusion of Gamunex-C, and the associated administration for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this is not covered for the enrollee's diagnosis.

The Plan must follow Medicare rules. Medicare rules say that IVIG can be covered if the patient has a diagnosis of primary immune deficiency disease. 

We looked at the file and Medicare rules. The file indicates the enrollee does not have a diagnosis of primary immune deficiency disease. 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 pre-approve in-home infusion of Gamunex-C, and the associated administration for the enrollee.