Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for foot orthotics provided on August 18, 2021.  You asked the Plan to pay for foot orthotics. You say that you have bone on the bottom of the ball of your left foot and have had very limited walking capability. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.          Therefore, we decided that the Plan does not have to pay for foot orthotics provided on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the knee.  You asked the Plan to pre-approve CT scan. You say that this is needed for the MAKO knee surgery the enrollee will undergo. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is being requested for planned MAKO knee surgery which is experimental.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   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 CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found this CT scan is not medically necessary because the planned MAKO knee surgery is considered to be experimental.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the knee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for diagnostic services provided on September 1, 2021.  You asked the Plan to waive the copayment for diagnostic services. You say that you have never paid for these services before. 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 $100 copayment for Diagnostic Procedures and Tests in an Outpatient Hospital.     You have been asked to pay a $100 copayment for diagnostic services. Diagnostic services falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 diagnostic services provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99202) provided on May 25, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you went in for a colonoscopy but did not have one. 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 $45 copayment for Physician/Practitioner services, including doctor's office visits.        You have been asked to pay a $45 copayment for a specialist office visit. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits 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 specialist office visit (99202) provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extremity study (96971) provided on September 19, 2021.  You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 96970 and 96971.  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 93971 is a column II code to column I code 93970. 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 extremity study (96971) provided on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99211) rendered by the out-of-network (OON) provider on May 9, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99211) rendered by the out-of-network (OON) provider on May 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 27, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you went in for a root canal. You also say that it does not make sense to start the procedure without first finding out what needs to be repaired. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.  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, problem focused limited oral evaluation (D0140) and is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on February 25, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) and continued glucose monitoring (99251) provided on September 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for office visit and continued glucose monitoring. You say that you would not have received services if it was not an emergency. The Plan denied your request. The Plan says you must receive your care from a network provider. The Plan also says that you, or your primary care provider (PCP), must obtain authorization from the Plan prior to seeking care.  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 at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that this does not meet criteria. Our physician reviewer found in this case, that the record indicates the enrollee had been diagnosed with diabetes type I and was being treated for worsening health in Arizona. The record indicates that the enrollee was seen in the emergency department in the state her daughter lives and then had several office visits. The family had the enrollee stay there to get better. The record indicates that the enrollee had an office visit in September 2021 before planning to transition to care in his/her home state in October. The need for care in a geriatric patient with worsening diabetes is foreseeable. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit have not been met.   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 pay for office visit and continued glucose monitoring. Therefore, we decided that the Plan does not have to pay for office visit (99214) and continued glucose monitoring (99251) provided on September 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 hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a C6-C7 Anterior Cervical Discectomy and Fusion and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  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 pre-approve 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 enrollee is scheduled/approved for a C6-C7 Anterior Cervical Discectomy and Fusion. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights.  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 pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-rays (D0270), cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality test (D0460), and incomplete root canal (D3332) provided on August 18, 2021.  You asked the Plan to pay for the dental services. You say that you followed all of the procedures to make sure the services would be covered. You also say that it was not your fault that the root canal could not be completed. The Plan denied your request. The Plan says 1 emergency diagnostic exam is covered per calendar year. The Plan says that 1 set of bitewing x-rays are covered per 12 month period. The Plan says that these frequency limits have been exceeded. The Plan also says that cone beam CT capture with interpretation, pulp vitality test, and incomplete root canal are not listed as covered 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 and emergency diagnostic exam and bitewing x-rays are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for an emergency diagnostic exam that you received on May 12, 2021. The record shows that the Plan paid for bitewing x-rays that you received on July 27, 2021. Additionally, the cone beam CT capture with interpretation, pulp vitality test, and incomplete root canal are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-rays (D0270), cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality test (D0460), and incomplete root canal (D3332) provided on August 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 14, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.    The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 76981 (ultrasound, elastography; parenchyma). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 76981. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 14, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  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. You have debility from acute illness and are medically stable. With your comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehab nursing needs are noted in the record. At the current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting. 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on July 29, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.      We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (RFA) provided on September 28, 2021.  You asked the Plan to pay for genicular nerve RFA. You say that this service was medically necessary and should be covered. The Plan denied your request. The Plan says the rendered procedure is considered experimental/investigational.  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 pay for genicular nerve RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure that was performed is considered experimental/investigational. Therefore, the procedure was 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 genicular nerve RFA have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve radiofrequency ablation (RFA) provided on September 28, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency visit provided on September 12, 2021.  You asked the Plan to waive the copayment for an emergency visit. You say that the clinic was closed so you went to the emergency room. 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 $120 copayment for each emergency room visit.     You have been asked to pay a $120 copayment for an emergency visit. An emergency visit falls within the Emergency 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 copayment for an emergency visit provided on September 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. Th enrollee is receiving appropriate inpatient care at the current facility and is unstable for transfer at this time. The enrollee can stay at the current acute care hospital until they are stable for discharge to a lower level of care.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate acute care at the current facility. There is no evidence that the enrollee requires services that are not currently available. As LTACH facilities and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain in the current setting until no acute services are required. Then the enrollee may be moved to a lower level of care for any long-term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0554) and sensors (K0553) provided on August 4, 2021.
You asked the Plan to pay for a continuous glucose monitor and sensors. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item. The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The medical records provided do not address the items at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0554) and sensors (K0553) provided on August 4, 2021.