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

We decided that the Plan does not have to pay for a prefabricated abutment (D6056) provided on February 8, 2021.
You asked the Plan to pay for a prefabricated abutment. You say that you disagree with the denial and is asking the plan to review and reconsider payment. The Plan denied your request. The Plan says the procedure code is not listed and therefore is not covered by the 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 prefabricated abutment service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a prefabricated abutment (D6056) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87500, 87640, 87653, and 
87798) provided on November 20, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen (codes 87481, 87500, 87640, and 
87653) was obtained in an office setting. 
 
Medicare rules also say that screening tests, with the exception of the few tests listed in the Medicare rules 
section, are not covered. The test at issue with code 87798 was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes.  
 
Therefore, we decided that the Plan does not have to pay for the laboratory services (87481, 87500, 87640, 
87653, and 87798) provided on November 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 1, 2021, to 
April 15, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed that you 
would owe a copayment for the last 9 days of the stay. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct 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 $0 
copayment for days 1-20 and a $150 copayment for days 21-100 for SNF care.  
 
The record shows that you had a SNF stay from March 17, 2021, to April 15, 2021. You are not being charged 
a copayment for days 1-20 (March 17, 2021, to April 5, 2021). You are responsible to pay a $150 copayment 
for days 21-29 (April 6, 2021, to April 14, 2021). The total amount you owe is: $150 (copayment) x 9 (SNF 
days) = $1,350.  
 
You have been asked to pay the total copayment amount of $1,350 for a SNF stay. A SNF stay falls within the 
SNF care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from 
April 1, 2021, to April 15, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs on May 5, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were told your
treatment would be covered and there would be no coinsurance for the medication. 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 20% coinsurance for in-network chemotherapy
drugs, infusion drugs, and all other drugs covered under Medicare Part B.
You have been asked to pay a total of $1,847.30 which is 20% of the allowed amounts for the chemotherapy
drugs. The total allowed amounts are $9,236.54. ($9,236.54 x 20% = $1,847.30). The chemotherapy drugs fall
within the "Medicare Part B prescription drugs" 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
coinsurance for the chemotherapy drugs on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment for specialist services on March 9, 2021. 
 
You asked the Plan to waive this copayment. You say that this visit was for a nosebleed resulting from a 
Covid-19 test and you believe the copayment should be waived. The Plan denied your request. The Plan says 
this copayment was charged based on the services provided and the Plan contract agreement. 
 
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 $45 
copayment for specialist visit. Medicare does not waive this type of copayment due to Covid-19 testing.  
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 $45 copayment charged for specialist services provided on 
March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power operated vehicle (K0806).
You asked the Plan to pre-approve a group 2 power operated vehicle. You say that the item is necessary. The Plan denied your request. The Plan says you have not had your current device for 5 years. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated vehicle (K0806).
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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility or home with home health services. 
 
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 non-surgical management of subdural hematoma and C1 and T1 vertebral fractures 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 medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve root canal therapy (D3347), and post removal (D2955).
You asked the Plan to pre-approve root canal therapy and post removal. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not covered 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. Specifically, the services are not listed in the Plan's benefit chart. This means the services are not covered. Therefore, we decided that the Plan does not have to pre-approve root canal therapy (D3347), and post removal (D2955).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that you require services that you are not 
currently receiving, but that would be available at the LTACH facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Specifically, medically necessary 
services can be obtained at a lower level of care. This means admission into a LTACH is not medically 
necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care 
hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 4, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 4, 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 4, 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 4, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond November 4, 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 4, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 4, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the introduction of a long gastrointestinal tube (44500) and 
septal strap placement (30999) provided on May 24, 2021. 
 
You asked the Plan to pay for the introduction of a long gastrointestinal tube and septal strap placement. You 
say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says reimbursement for tube and septal strap placement for anchoring the tube is bundled into the DRG for the 
member's hospitalization. 
 
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 44500 is introduction of long gastrointestinal tube (eg, 
Miller-Abbott) (separate procedure). 
 
The CPT Code Manual definition of code 30999 is unlisted procedure, nose.  
 
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 introduction of a long gastrointestinal tube and septal 
strap placement. Our reviewer says that CPT code 44500 does not meet criteria for billing or reimbursement 
consideration. The record does not include enough documentation to support insertion of long gastrointestinal 
tube.  Per procedure report " A nasogastric Corpak feeding tube was placed via the right nare and secured with 
an AMT nasal septal bridal system.  An abdominal X-ray was ordered to confirm proper placement of the 
tube".  A corpak medical system can be inserted via the nose or mouth and placed in the stomach, as well as in 
the duodenum, jejunum.   Documentation does not include the point the tube was inserted to, and therefore 
cannot be verified. Our reviewer found CPT code 30999 does not meet criteria for billing or reimbursement 
consideration. The provider billed this code for a "septal bridal system", however, this would be included with 
the primary service. 
 
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 introduction of a long gastrointestinal tube and septal strap placement have 
not been met. Therefore, we decided that the Plan does not have to pay for the introduction of a long 
gastrointestinal tube (44500) and septal strap placement (30999) provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a wheelchair purchased on January 14, 2021.
You asked the Plan to pay for this wheelchair. You say that the Plan should cover this wheelchair. The Plan
denied your request. The Plan says you did not have prior authorization for this wheelchair and the provider is
not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a provider who is not a Medicare eligible provider. The Plan contract
says that durable medical equipment requires prior authorization. This provider is not a Medicare eligible
provider and you did not have prior authorization. Therefore, we decided that the Plan does not have to pay for
a wheelchair purchased on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas treatment provided on January 13, 2021.
You asked the Plan to pay for Sanexas treatment. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for these services is correct, because these
services are not covered by Medicare under the circumstances.
The Plan must follow Medicare rules. Medicare rules state that Medicare pays for outpatient physical therapy
services only if they are furnished by, or under the direct supervision of, a physical therapist in private practice;
or by or incident to the services of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA
may perform physical therapy services under state law. Medicare rules state that modifier -25 is defined as a
significant, separately identifiable evaluation and management service. Medicare rules state that compounded
drugs should be submitted using a compounded drug not otherwise classified code.
We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the
physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide
physical therapy in the State of Oklahoma. The office visit at issue was billed with modifier 25, which is used
to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician
or other qualified health care professional on the same day of a procedure or other service. There is no
documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the
enrollee on this date of service. The multiple drug codes reported on this claim refer to a pre-filled compounded
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified
code J7999. As these compounded drugs were not billed properly, payment cannot be made. Because the drugs
are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we
decided that Medicare rules for coverage of Sanexas treatment have not been met. Therefore, we decided that
the Plan does not have to pay for Sanexas treatment provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home infusion therapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve continued home infusion therapy services. You say that this provider has been serving the enrollee since October 2020. The Plan denied your request. The Plan says this is available in-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 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 continued home infusion therapy services to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.
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