Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional services rendered on November 9, 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 procedure code 99072 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and
clinical staff time over and above those usually included in an office visit or other non-facility service(s), when
performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious
disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan
does not have to pay for the additional services rendered on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the erupted tooth extraction rendered on June 10, 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 a covered 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. The extraction is not covered by your medical benefit because it was
not performed to prepare the jaw for radiation treatments. Therefore, we decided that the Plan does not have to
pay for the erupted tooth extraction rendered on June 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the intravenous drugs you received on March 15, 2021, and March 16, 2021, and the inpatient hospital services you received from March 8, 2021, to March 11, 2021.

You asked the Plan to waive the cost sharing for the drugs and the inpatient hospital services. You say that you had a reaction to the Coronavirus vaccine that necessitated this care. You believe that because these services were related to the Coronavirus that the copayments should be waived. The Plan denied your request. The Plan says it is only waiving copayments related to the treatment of the Coronavirus. You received these services due to an adverse reaction to the vaccine, not from the virus itself. Therefore, the Plan says that you were charged this cost sharing 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 20% coinsurance for Medicare Part B drugs and a $125 copayment for inpatient hospital services.

You have been asked to pay 20% coinsurance for the drugs and a $125 copayment for the inpatient hospital services. According to the Plan's website, they are only waiving cost sharing for in-network observation and inpatient hospital services to treat the Coronavirus. Because you did not have the Coronavirus (just a reaction to the vaccine), this is not covered under the Plan's cost sharing waiver program. 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 cost sharing for the intravenous drugs you received on March 15, 2021, and March 16, 2021, and the inpatient hospital services you received from March 8, 2021, to March 11, 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 the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.

You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99213) provided on July 6, 2021.
You asked the Plan to waive the copayment for an office visit with a specialist. You say that you did not have an appointment with a specialist on this date of service. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $40 copayment for an office visit with a specialist. The EOC confirms that $40 is the required copayment for this service. An office visit with a specialist falls 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 an office visit with a specialist (99213) provided on July 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on November 5, 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 enrollee was on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on November 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on November 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound you had on May 10, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that this was a medically necessary service that was covered last year, so the Plan should pay for it. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($77.39) 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 $110 copayment for radiological diagnostic services (including ultrasounds). 

You have been asked to pay a $110 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic 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 retroperitoneal ultrasound you had on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided
on January 16, 2021.
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code
99291.
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 99291 is Critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent
providing services to the enrollee. The progress note for January 16, 2021 does not note how much time was
spent providing services to the enrollee. As such, the provided documentation does not support the billing of
code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not
been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by
code 99291 provided on January 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need assistance with daily activities such as dressing yourself and are in need of occupational therapy and physical therapy. The Plan denied your request. The Plan says the stay 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or

rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.

You asked the Plan to pre-approve radiofrequency ablation services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this benefit has been exhausted at this time.

The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

We looked at the file and Medicare rules. In this case, the documentation supports that 2 radiofrequency sessions have already been covered. At this time, an additional session is not eligible for coverage based on Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the 20% coinsurance on a ventilator on February 13, 2021.

You asked the Plan to pay for the coinsurance. You say that you would like to dispute the coinsurance as you would struggle to afford it. The Plan denied your request. The Plan says the copayments are contractual obligations that cannot be waived.

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 20% coinsurance for the Durable Medical Equipment. 

You have been asked to pay 20% coinsurance for the durable medical equipment. The coinsurance falls within the Durable Medical Equipment 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 pay for the 20% coinsurance on a ventilator on February 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a partial upper denture to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 a partial upper denture (D5213) 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 pre-approve a custom implant abutment, extraction, endosteal implant, implant complete denture, removal of tooth roots, cone beam computed tomography (CT), unspecified preventive procedure, surgical stent, implant index, and repair tissue defect head.

You asked the Plan to pre-approve a custom implant abutment, extraction, endosteal implant, implant complete denture, removal of tooth roots, cone beam computed tomography (CT), unspecified preventive procedure, surgical stent, implant index, and repair tissue defect head. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered 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 a custom implant abutment, extraction, endosteal implant, implant complete denture, removal of tooth roots, cone beam computed tomography (CT), unspecified preventive procedure, surgical stent, implant index, and repair tissue defect head.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON second opinion. You say that you were seen by doctors at the requested OON facility several years ago for your prostate issues. You say that you were advised to monitor the condition. You say that you are being recommended surgery and would like to get a second opinion, due to the risks involved with surgery. The Plan denied your request. The Plan says the enrollee's treatment can be managed with the Plan network and a second opinion can be obtained within this 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 a second opinion. We found no exception that would require the Plan to pre-approve a second opinion with an OON provider. Therefore, we decided that the Plan does not have to pre-approve a second opinion 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 bone replacement graft for ridge preservation - per site (D7953), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided May 15, 2021.

You asked the Plan to pay for the bone replacement graft, deep sedation and dental consultation. You say that you have anxiety going to the dentist and it was necessary to be sedated to have your teeth extracted. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 bone replacement graft for ridge preservation - per site (D7953), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-minute increment (D9223), and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable pull up briefs.

You asked the Plan to pre-approve disposable pull up briefs. You say that the items are necessary. The Plan denied your request. The Plan says the requested items are not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve disposable pull up briefs.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way and an additional 30 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.