Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings (D0274), and prophylaxis (D1110) provided by an
out-of-network provider on August 2, 2021.
You asked the Plan to pay for bitewings, and prophylaxis. You say that you are not sure why the Plan isn't
paying for this. The Plan denied your request. The Plan says that the enrollee does not have dental coverage.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for bitewings (D0274), and
prophylaxis (D1110) provided by an out-of-network provider on August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that that it is not safe for you
to go home. The Plan denied your request. The Plan says that the records received show that your condition has
improved and you are no longer a threat to yourself or others.
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 hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is
not expected you would improve in a reasonable period of time as you do not have suicidal or homicidal
ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any
symptoms which would require acute treatment. It does 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 you do not have
dangerousness to self or others and were compliant with your treatment. Our physician reviewer found that
your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit on June 1, 2021.
You asked the Plan to pay for the psychotherapy visit. You say that you cannot afford the therapy sessions you
need. You say your mental health that had improved temporarily has worsened. The Plan denied your request.
The Plan says the provider is ineligible with Medicare
The Plan must follow Medicare rules. Medicare rules say that the rules state that to receive payment for
covered Medicare items or services from either Medicare or a Medicare beneficiary, a provider or supplier
must be enrolled in the Medicare program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy visit have not been met. The record shows that this provider is a Licensed
Clinical Mental Health Counselor. LCMHCs are not eligible to enroll in Medicare, therefore this provider is
not payable. Therefore, we decided that the Plan does not have to pay for the psychotherapy visit provided on
June 1, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found based on the medical records provided, you do require skilled nursing services on an inpatient basis in a skilled nursing facility setting for the intravenous antibiotics through December 24, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy (45380)
provided by an in-network outpatient hospital on May 24, 2021.
You asked the Plan to waive the copayment for a colonoscopy with biopsy. You say that you shouldn't have to
pay for a preventive colonoscopy. You say you have a history of colon cancer and were advised to get a
screening. The Plan denied your request. The Plan says upon review of the claim submitted for your colorectal
cancer screening, it was determined that the procedure was diagnostic in nature. The Plan says of the removal
of a polyp or if a biopsy is conducted during a preventive colorectal cancer screening, it is considered a
diagnostic procedure, which requires a different copayment. The Plan says the cost-sharing was applied
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 $200
copayment for Outpatient Hospital Services.
You have been asked to pay a $200 copayment for a colonoscopy with biopsy. A colonoscopy with biopsy falls
within the Outpatient Hospital 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 a colonoscopy with biopsy (45380) provided by an in-network outpatient hospital on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on June 29, 2021.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you were not put in a treatment room, you were in an office. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($234.56) is less than your copayment obligation, you are responsible for the full allowed 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 $275 copayment for outpatient hospital services.
You have been asked to pay a $275 copayment for the arthrocentesis procedure. The facility that performed this service is considered an outpatient hospital facility. That is why the outpatient hospital cost sharing applies. 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 arthrocentesis procedure you had at an outpatient hospital facility on June 29, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded as 99284, 93005, 87635, 85025, 84484, 83880, 83605, 80053 and 71045 provided October 23, 2020 to October 24, 2020 by an out of network provider.
You asked the Plan to pay for the emergency visit. You say that the place of service is correct and the claim was billed correctly. Your credentials were approved by Medicare and the claim should be paid at the Medicare reimbursement rates. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the emergency department visit coded as 99284, 93005, 87635, 85025, 84484, 83880, 83605, 80053 and 71045 provided October 23, 2020 to
October 24, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve precision attachments (D6950) for tooth #6 and tooth #7.
You asked the Plan to pre-approve the precision attachments. You say that these services are necessary to keep the upper denture in place without stressing the natural teeth. The Plan denied your request. The Plan says these services are not covered by the enrollee's 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, 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 precision attachments (D6950) for tooth #6 and tooth #7.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a high dose (65+) flu vaccine.
You asked the Plan to provide coverage for the high dose flu vaccine. You say that you should be able to have the flu vaccine you choose. The Plan denied your request. The Plan says the Center for Disease Control has indicated there essentially is not a difference between the efficacy of one over the other.
Under PACE rules and for Pace enrollee's, for anything to be covered the requested service must be determined necessary by your interdisciplinary team (IDT). There is no evidence that you have gone to your interdisciplinary team to ask for coverage of the higher dose flu vaccine. Since there is no evidence that your interdisciplinary team has determined the vaccine is appropriate for you or that your team can support this request, this vaccine requested is not covered. Therefore, we decided that the Plan does not have to provide coverage for a high dose (65+) flu vaccine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee has multiple medical issues which increase the risk for mortality and falls in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K0801 heavy duty power mobility device.
You asked the Plan to pre-approve the requested device. You say that you believe it's unfair that you are not
granted this equipment because you do not meet the weight requirement. The Plan denied your request. The
Plan says Medicare rules are clear about coverage for the specific equipment requested.
The Plan must follow Medicare rules. The rules say a K0801 heavy duty power mobility device has a weight
expectation. You do not meet that weigh expectation. Therefore, we decided that the Plan does not have to pre-
approve a K0801 heavy duty power mobility device
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spinergy LX wheels for a manual wheelchair.
You asked the Plan to pre-approve Spinergy LX wheels. You say that the Plan supplied the same wheels on
your previous wheelchair. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose and be appropriate and needed for use inside the home.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Furthermore, the
item at issue is primarily for use outside of the home. Although this item may be helpful, neither Medicare nor
the Plan covers equipment that is not primarily medical in nature nor equipment that is for use outside the
home. Therefore, we decided that the Plan does not have to pre-approve Spinergy LX wheels for a manual
wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra testing strips.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from preferred providers.
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers
for durable medical equipment and supplies.
We looked at the file and Medicare rules. The requested OneTouch Ultra test strips are not from the Plan's
preferred provider. Test strips are available from the Plan's preferred provider. Therefore, we decided that the
Plan does not have to pre-approve OneTouch Ultra testing strips.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on May 10, 2021, through
May 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary.
The Plan denied your request. The Plan says that the services could have been obtained at an observational
level of care.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span
two 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided on May 10, 2021, through May 12, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 26, 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 included in the global surgical package.
The Plan must follow Medicare rules. The rules say that all additional medical or surgical services required of
the surgeon during the postoperative period of the surgery are included in the global surgical package.
We looked at the file and Medicare rules. Billed procedure codes 11057 (paring or cutting of benign
hyperkeratotic lesion, more than 4 lesions) and 11720 (debridement of 1-5 nails) were rendered in relation to
major surgical code 28010 billed on December 14, 2020. These services were billed within the 90 day global
surgical period for the major surgical procedure and payment is included in the global surgical package.
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 26,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear for the enrollee for lymphedema.
You asked the Plan to pre-approve orthopedic footwear. You say that these shoes are medically necessary. 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. The records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear for the enrollee for lymphedema.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided to the enrollee on
April 2, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied code remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Medicare rules say that DME supplies must be
provided with a proof of delivery.
In this case, the CPT Code Manual definition of code E0627 is "Seat lift mechanism, electric, any type."
We find that durable medical equipment code E0627 is not supported in the medical record. Specifically, the
required documentation pertaining to the proof of delivery of these supplies was not provided. Based on this
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we
decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided to the enrollee on
April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tenotomy services coded as 28010 provided on May 20,
2021.
You asked the Plan to pay for the tenotomy services. You say that you would like this claim reprocessed based
on the medical documentation provided. The Plan denied your request. The Plan says the documentation does
not support the claim 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, the CPT Code Manual definition of code 28010 is tenotomy, percutaneous, toe; single tendon.
We asked our coder 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 the tenotomy services. Our reviewer says that the
documentation does not support the services as billed. Our reviewer found the medical records provided do not
include documentation of tenotomy, percutaneous, toe, single tendon being performed on May 20, 2021,
therefore this procedure cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the tenotomy services have not been met. Therefore, we decided that the Plan
does not have to pay for the tenotomy services coded as 28010 provided on May 20, 2021.