Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99307) provided April 28, 2021.
You asked the Plan to pay for the nursing facility care. You say that the enrollee is a resident in a nursing home and has an authorization on file for all care at the facility, including consultations. The Plan denied your request. The Plan says this service exceeds the maximum allowed units billed per date of 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, we find that CPT code 99307 is not supported in the medical record. Specifically, this claim is a duplicate of another claim billed by the same provider on the same date of service. This claim was processed on check dated 05/19/2021. Based on this information, we decided that Medicare rules for coverage of the nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99307) provided April 28, 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 you refuse to go to the skilled nursing facility for fear of not getting appropriate care, and you need an intensive rehabilitation program. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. While you may need 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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benicar HCT.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Benicar HCT.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture (D5213) and resin-based composite, two surfaces, anterior (D2331) provided May 11, 2021.
You asked the Plan to pay for the dental services. You say that the insurance was charged more than you were quoted. You were quoted $885. The insurance paid out $1,809 which used all your insurance for the year. If you would have been quoted this amount you would have never had partial done. The Plan denied your request. The Plan says the benefit maximum has been met.
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 any amount over the $2,000 combined allowance for supplemental preventative and comprehensive dental services every year for Dental services.
You have been asked to pay $170 for the dental services. The records show that the enrollee had dental claims paid in the amount of $2,000. The services falls within the Dental 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 pay for the upper partial denture (D5213) and resin-based composite, two surfaces, anterior (D2331) provided May 11, 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. The Plan denied your request. The Plan says the enrollee is receiving adequate intensive rehabilitation in the intensive rehabilitation facility.

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 services. Our physician reviewer found that the enrollee has no daily skilled nursing needs. Her progress in the inpatient rehabilitation facility (IRF) is slow. With no documented daily skilled nursing needs and at the current level of slow functional recovery, she does not require daily skilled therapies in an inpatient setting. The documentation does not support the need for an admission to SNF. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 25, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you should not owe the copayment because this was a post-operative follow-up and you did not receive an examination. 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 $40 copayment for specialist visits. The medical records show that you had a specialist visit on March 25, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on March 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician or allowed practitioner certification for Medicare-covered home health services under a home health plan of care (G0180) provided on September 18, 2020.

You asked the Plan to pay for the physician or allowed practitioner certification. You say that the enrollee did not have any hospice encounters. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the physician or allowed practitioner certification for Medicare-covered home health services under a home health plan of care (G0180) provided on September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of chest before and after contrast (71552).
You asked the Plan to pre-approve a MRI scan of chest before and after contrast. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says the previous procedure was sufficient in this case.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI scan of chest before and after contrast. Our reviewer says that the requested imaging service is not medically necessary and reasonable. Our physician reviewer found that you are a female who had an MRI scan of the chest from 2016 which showed a mediastinal mass. The computed tomography (CT) scan of the chest from May 2021 showed mediastinal mass unchanged in size. Repeat MRI chest was requested. Based on the fact that you already had imaging to show the mass size was unchanged from prior test years prior without change in symptoms and without other findings on recent CT, there was no indication or justification for the repeat MRI thorax. Therefore, this request for such will be considered not medically necessary at this time. 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 MRI scan of chest before and after contrast have not been met. Therefore, we
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of chest before and after contrast (71552).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 5, 2021.

You asked the Plan to pay for the dental service. You say that you had a dental emergency while you were out of town. You say that you had to see a dentist for an abscess that needed immediate attention. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit has been exceeded.

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 and the service is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a comprehensive oral exam that you receive don August 13, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 5, 2021.
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 March 2, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you do not feel like the provider did any of the services that are showing on the claim and you would like reconsideration of the copayment. 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 $35 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $35 copayment for an office visit. The EOC confirms that $35 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 March 2, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0842, E1007, E2313, E2311, E2377, E2361, E0955, E1026, E2603).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the mobility deficit could not be handled by a manual wheelchair. As the records do not document fully the need for the requested wheelchair, the requested accessories are not eligible for coverage either. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0842, E1007, E2313, E2311, E2377, E2361, E0955, E1026, E2603).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 a power wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 12, 2021.
You asked the Plan to pay for the dental service. You say that you told your dentist that you needed your front eyetooth to be extracted. You say that your dentist advised they would pull all 11 teeth and put in dentures right away. You say that you did not have your tooth extracted. You also say that you will not pay this bill. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says the frequency limit has been exceeded.
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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 5, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on January 4, 2021.
You asked the Plan to pay for the core build up. You say that you had 2 crowns that needed replacement. You say that nothing extra or fancy was done. You also say that you do not understand why the services are not covered. The Plan denied your request. The Plan says core build up is not listed as 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on January 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency wheelchair van transportation (A0130-HN,
S0209-HN, A0999-HN) provided on October 17, 2020.
You asked the Plan to pay for non-emergency wheelchair van transportation. You say that were told you would
only have to pay $50. The Plan denied your request. The Plan says the services at issue are not a covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided
that the Plan does not have to pay for non-emergency wheelchair van transportation (A0130-HN, S0209-HN,
A0999-HN) provided on October 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on May 4, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you did not know that you were only entitled to one bitewing x-ray per year. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.
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, bitewing x-rays (codes D0270, D0272, D0273, D0274, and D0277) are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on February 11, 2021 and your bitewing x-rays (D0274) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (95249 and 95250).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (95249 and 95250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Escitalopram Oxalate.
You asked the Plan to pre-approve the Escitalopram Oxalate. The Plan denied your request. The Plan says this
drug is not covered for the enrollee's condition by Medicare Part B. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Escitalopram Oxalate.
Benefits for Escitalopram Oxalate may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing rendered on January
6, 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 were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when
specific criteria are met.
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 these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant
neoplasm of unspecified site of unspecified female breast. The case file contains a Test Requisition Form, a
Hematology report, and the results of the testing. There are no clinical medical records for review. The
documentation does not support that all of the coverage criteria established by NCD 90.2 for FoundationOne
Liquid CDx testing have been met. The testing is therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the FoundationOne Liquid CDx testing rendered on January 6, 2021.