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

We decided that the Plan does not have to pay for the retainer crown - porcelain/ceramic (D6740) and pontic -
porcelain fused to predominantly base metal (D6241) provided March 30, 2021.
You asked the Plan to pay for the retainer crowns and pontic. You say that you expected there to be some
coverage for the services. 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
retainer crown - porcelain/ceramic (D6740) and pontic - porcelain fused to predominantly base metal (D6241)
provided March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), pulp vitality tests (D0460), endodontic therapy (D3330), and consultation (D9310) provided on June 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the first intraoral periapical x-ray, pulp vitality tests, endodontic therapy, and consultation. You say that you were unaware that the treating provider was OON. You also say that you thought any cost share that was not covered by Medicare would be covered by Medicaid because of the Plan you have. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), pulp vitality tests (D0460), endodontic therapy (D3330), and consultation (D9310) provided on June 3, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 36247, 75726, 76937, and 99152 provided on March 9, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical records. The Plan denied your request. The Plan says these claims have denied correctly. must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Specifically, the record indicates that this is an exact duplicate of another claim that has been processed and paid. Additionally, the documentation submitted does not include a description of why modifier -77 was needed. Per Medicare guidance, failure to report modifier -77 and the unusual circumstances in the narrative portion of the claim will result in a claim rejection. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 36247, 75726, 76937, and 99152 provided on March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that SNF placement is not appropriate for generalized weakness.
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. e 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does 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 this 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: SNF
Decision: Unfavorable

We decided that the Plan does not have 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 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 daily skilled services are not necessary. Our physician reviewer found based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided from March 11, 2021, to May 10, 2021.
You asked the Plan to waive the copayments for the psychotherapy visits. You say that you do not want to be responsible for any copayments for your sessions. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $40 copayment for each Medicare-covered individual session for outpatient mental health services provided by a mental health professional other than a psychiatrist.
You have been asked to pay a $40 copayment for each of the psychotherapy visits. The psychotherapy visits fall within the "Outpatient mental health 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 copayments for the psychotherapy visits provided from March 11, 2021, to May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that Vertiflex would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is 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 pre-approve Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex devices is experimental, more research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851), suspension sleeve (L2397), heel stabilizer (L3170), and ankle foot orthosis (L1971), provided on February 8, 2021.

You asked the Plan to pay for the orthotics. You say that the items were medically necessary. The Plan denied your request. The Plan says the enrollee was contacted by telephone.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthotics have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851), suspension sleeve (L2397), heel stabilizer (L3170), and ankle foot orthosis (L1971), provided on February 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental
gradient pressure pneumatic appliance (E0673), provided on March 11, 2021.

You asked the Plan to pay for the pneumatic compression device and segmental gradient pressure pneumatic
appliance. You say that the service was medically necessary. The Plan denied your request. The Plan says the
enrollee used the equipment in the facility during and/or after surgery.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that the pneumatic compression device and segmental gradient pressure pneumatic appliance
was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the pneumatic
compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673), provided on March
11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 21, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate biopsy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a prostate biopsy 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 prostate biopsy to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift chair (E0627), provided on March 2, 2021.
You asked the Plan to pay for the seat lift chair. You say that the item should be covered. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for reimbursement of the seat lift chair and mechanism have not been met. Specifically, Medicare does not cover seat lift chairs. Coverage is limited to the seat lift mechanism. The record indicates that the Plan has reimbursed you for the seat lift mechanism. Therefore, we decided that the Plan does not have to pay for the seat lift chair (E0627), provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation services coded as 99254 provided on September 11, 2020.
You asked the Plan to pay for the inpatient consultation services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99254 is inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99254 is not eligible for payment. Specifically, code 99254 has a status code of "I" which means that it is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the inpatient consultation services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation services coded as 99254 provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and accessories to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a CPAP device and accessories 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 continuous positive airway pressure (CPAP) device and accessories to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have 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 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 daily
skilled services are not necessary. Our physician reviewer found admission to an SNF is not reasonable and not
necessary as you have no skilled nursing needs and does not need skilled therapies on a daily basis in an
inpatient setting at the current functional level. Documentation does not support the need for an admission to an
SNF. Your rehabilitation needs can be met at a lower intensity level.

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 not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the electronic analysis of an implanted neurostimulator pulse generator/transmitter (95976) and the office visit (99214) provided on June 4, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 specialist physician services. Additional cost-sharing applies for diagnostic and radiology services received at physician offices. Additionally, you pay a $50 copayment for all other Medicare-covered outpatient diagnostic tests. If you receive services in addition to outpatient diagnostic tests and therapeutic services, a separate cost-sharing may apply. For any services received in an outpatient facility, a separate cost-sharing may apply. You have been asked to pay $90.12 which includes a $45 copayment for the specialist physician visit provided. Additionally, this amount includes a $45.12 copayment for the outpatient diagnostic service provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 adjust the copayment for the electronic analysis of an implanted neurostimulator pulse generator/transmitter (95976) and the office visit (99214) provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and endodontic therapy (D3310).
You asked the Plan to pre-approve a comprehensive oral evaluation, and endodontic therapy. You say that you were referred to this provider by your general dentist. The Plan denied your request. The Plan says the comprehensive oral evaluation is not covered unless it is performed by a participating general dentist. Dental services performed by an endodontist are not covered. Endodontic therapy is not a covered service.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and endodontic therapy have not been met. Specifically, the comprehensive oral evaluation is not covered unless it is performed by a participating general dentist. Additionally, endodontic therapy is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and endodontic therapy (D3310).