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

We decided that the Plan has to pay for the back orthosis provided on March 30, 2021.
You asked the Plan to pay for the back orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the records do not contain documentation of a written order prior to the delivery of the item to the enrollee.
The Plan must follow Medicare rules. Medicare rules say that DMEPOS is covered only when there are both a physician order and proof of delivery. We looked at the file and Medicare rules. Review of the file shows that the Plan states that the records do not contain documentation of a written order prior to the delivery of the item to the enrollee. However, the documentation shows that the detailed written order was dated March 26, 2021 and the item was delivered on March 30, 2021. This means that there was a written order prior to the delivery of the item to the enrollee. Based on this information, we decided that Medicare rules for coverage of the back orthosis have been met. Therefore, we decided that the Plan has to pay for the back orthosis provided on March 30, 2021.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance mileage (billed with code A0425) provided on December 3, 2020.
You asked the Plan to pay for the ambulance mileage.. You say that your ambulance company only bills in whole, not fractional, units. The Plan denied your request. The Plan says you did not bill the ambulance mileage correctly.
The Plan must follow Medicare rules. Medicare rules say that ambulance mileage must be billed in fractional units to the nearest tenth of a mile. We looked at the file and Medicare rules. You did not bill your claim using fractional units rounded to the nearest tenth of a mile. Rather, you just billed for 9 full miles with no fractions.
According to online maps, the distance between the pickup location and the destination is 8.5 miles, so you should have billed using the appropriate fraction of miles on your claim. Based on this information, we decided that Medicare rules for coverage of the ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance mileage (billed with code A0425) provided on December 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram with digital 
breast tomosynthesis you had on August 10, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you have been 
getting this service for years and have never had to pay anything.  You said this should be considered a 
preventive screening at no charge. The Plan denied your request. The Plan says you were charged this 
copayment 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 $35 
copayment for basic imaging services.  
 
You have been asked to pay a $35 copayment for the diagnostic mammogram. The records from your doctor 
clearly show that this was ordered as a diagnostic, not screening, mammogram.  Only screening mammograms 
are covered with no copayment. The diagnostic mammogram falls within the basic imaging services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the diagnostic mammogram with digital breast 
tomosynthesis you had on August 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there no skilled nursing or acute skilled therapy needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6240) and retainer crowns (D6750) provided on July 7, 2021.
You asked the Plan to pay for the pontic and retainer crowns. You say that these services were for a bridge repair and should be covered at 50%. The Plan denied your request. The Plan says these services are not covered benefits under the 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 pontic (D6240) and retainer crowns (D6750) provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, simple extraction, and inhalation of nitrous oxide/analgesia provided on February 18, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the problem focused limited oral evaluation, simple extraction, and inhalation of nitrous oxide/analgesia. You say that the provision of not opting out was not in the 2020 Evidence of Coverage, nor was it stated in the Annual Notice of Change (ANOC) that you received last fall. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds. The Plan also says that you made no contacts to the Health Plan in regard to your cost share or provider questions prior to receiving these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, simple extraction, and inhalation of nitrous oxide/analgesia provided on February 18, 2021 by a Medicare opt out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 6, 2021,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 6, 2021, forward. You say that
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue
are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care from
November 6, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental
health treatment beyond the date in question of November 6, 2021, forward. Our physician reviewer found you
did not require inpatient mental health treatment beyond November 6, 2021, as you were not a danger to
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active
treatment was taking place beyond the date in question. It did not appear that the services for the dates in
question were reasonably expected or medically necessary to improve your condition or for the purpose of
diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from November 6, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 6,
2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from June 18, 2021, to June 21, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the only drugs you received after your surgery were for pain. You say that the medicine was provided at the hospital. You say that you did not request the drugs. You also say that they were prescribed to you as part of the treatment after surgery. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under 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 pay for the self-administered drugs provided in an outpatient setting from June 18, 2021, to June 21, 2021.
Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient mental health admission.
You asked the Plan to pre-approve an inpatient mental health admission to be provided at the hospital. You say that an inpatient mental health admission is medically necessary. The Plan denied your request. The Plan says an inpatient mental health admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 an inpatient mental health admission. Our reviewer says that an inpatient mental health admission is not medically necessary. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health Plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient mental health admission to be provided at the hospital have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient mental health admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3410), initial 15 minutes of intravenous (IV) conscious sedation (D9239), and additional 15 minutes of IV conscious sedation (D9243) provided on May 28, 2021.
You asked the Plan to pay for the dental services. You say that this was not a dental procedure. You say that you had a cyst on your gum. You say that you needed to see an oral surgeon for this service. You also say that a plan representative advised that the oral surgeon needs to code this differently. The Plan denied your request. The Plan says the apicoectomy is not listed as a covered service. The Plan also says that IV conscious sedation is not listed as a covered 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 apicoectomy and IV conscious sedation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the apicoectomy (D3410), initial 15 minutes of intravenous (IV) conscious sedation (D9239), and additional 15 minutes of IV conscious sedation (D9243) provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental crown represented by dental code D2740 provided on May 4, 2021.
You asked the Plan to pay for dental code D2740. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D2740 is not covered under the Plan's supplemental dental 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, dental code D2740 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental crown represented by dental code D2740 provided on May 4, 2021.
Your complaint about not being informed in advance of your dental benefit changes is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from August 19, 2020, to February 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the dental services. You say that shortly before August 2020 you contacted the Plan and were advised that this treating provider was in-network. You also say that you would like these services to be paid. The Plan denied your request. The Plan says the treating provider is not a participating provider with the Plan. The Plan also says that you did not contact the Plan prior to receiving these services to verify the treating provider's participation status.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the dental services provided from August 19, 2020, to February 25, 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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
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 there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon your
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy.
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented
skilled nursing needs. While you may benefit from physical therapy and occupational therapy, your
rehabilitation needs can be safely met in an alternate and lower intensity setting.
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: 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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
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 there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
enrollee's current level of function, the enrollee does not require an intensive, complex, multidisciplinary
approach to daily therapy. Documentation does not support the need for a therapy program consisting of at
least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation
care. There are no documented skilled nursing needs. While the enrollee may benefit from physical therapy and
occupational therapy, his rehabilitation needs can be safely met in an alternate and lower intensity setting.
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 pay for the injection services coded 64447 and the anesthesia services coded 01402 provided on May 19, 2021.
You asked the Plan to pay for the injection services and the anesthesia services. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as
billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64447
for the injection services is a column II code to column I code 01402. 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.
Medicare rules say that providers must report services correctly. Providers must report services with the
appropriate CPT code. We find that code 01402 is not supported in the medical record. Specifically, the
medical records submitted include the anesthesia pre-evaluation and postoperative evaluation notes; however,
the records didn't include the intraoperative anesthesia records. Based on this information, we decided that
Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for the injection services coded 64447 and the
anesthesia services coded 01402 provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobilization of splenic flexure coded 44139 provided on January 11, 2021.
You asked the Plan to pay for the mobilization of splenic flexure. 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 44319 for the mobilization of splenic flexure is an add-on code and has not been billed with an appropriate primary procedure code. 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 mobilization of splenic flexure coded 44139 provided on January 11, 2021.