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

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are walking more than 100 feet. You will have some limitations due to the weight bearing restriction. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.

You asked the Plan to pre-approve skilled nursing facility services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the limited documentation provided, the enrollee does not have documented skilled therapy needs. The enrollee is not shown to be below her baseline, progressing with therapy or willing/able to participate in therapy. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011), custom fabricated abutment (D6057), and abutment supported crown (D6058) for tooth # 11.  You asked the Plan to pre-approve the dental services. You say that the implant placement was previously approved. You say that the services were covered in 2020. You also say that you would like these services to be covered in 2021. The Plan denied your request. The Plan says surgical access to an implant body is not listed as a covered service. The Plan says that custom fabricated abutment is not listed as a covered service. The Plan also says that abutment supported crown is not listed as a covered service either.  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 surgical access to an implant body (D6011), custom fabricated abutment (D6057), and abutment supported crown (D6058) for tooth # 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup (D2950) provided by a participating provider.  You asked the Plan to pre-approve a core buildup. You say that you would like approval for these services. The Plan denied your request. The Plan says the requested dental service is 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 core buildup (D2950) provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional non-emergency routine transportation trips.  You asked the Plan to provide coverage for additional non-emergency routine transportation trips. You say that  you need transportation to complete acupuncture treatment for your back condition. The Plan denied your request. The Plan says you have exhausted the benefit.  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 24 one-way trips per year.   We looked at your request, the records in the case file, and the rules. The file shows that you have used the maximum number of transportation trips for this year. 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 provide coverage for additional non-emergency routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing and supplies billed to the enrollee for March 1, 2021 under codes A4221 and A4222.

You asked the Plan to pay this claim. The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 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 these supplies. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the documentation submitted does not include a delivery ticket for date of service billed March 1, 2021.

We looked at this coder's review, the file, and Medicare rules. Based on this information the Medicare rules for coverage of this claim are not met. Therefore, we decided that the Plan does not have to pay for drug testing and supplies billed to the enrollee for March 1, 2021 under codes A4221 and A4222.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 29, 30, and 31, and general anesthesia (D9222).

You asked the Plan to pre-approve the dental services. You say that you had your old bridge removed. You say that you your dentist was not able to repair crown. You also say that you need these services. The Plan denied your request. The Plan says implants are not covered services.

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 implants are not among those covered under this benefit. Since Implants are not covered, the associated anesthesia is not covered either. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 29, 30, and 31, and general anesthesia (D9222).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.

You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the general health panel rendered on June 24, 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 covered.  The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by Medicare.  You have requested payment for a GHP, billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve osseous surgery (D4260 x 2), and bone replacement grafts (D4263 x 2).  You asked the Plan to pre-approve the dental services. You say that you need surgery. You say that you are in pain. You say that it hurts you to chew even soft food. You also say that you are on a fixed income. The Plan denied your request. The Plan says osseous surgery is not listed as a covered service. The Plan says that bone replacement grafts are not listed as covered services either.  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 osseous surgery and bone replacement grafts are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve osseous surgery (D4260 x 2), and bone replacement grafts (D4263 x 2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 16, 2020 and billed under codes 27695, 28230, and 20902.

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 Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 

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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found for code 27695; the operative report does not include enough information to confirm lateral collateral ligament. The documentation describes spring ligament was used to support the medial column; therefore, this procedure cannot be confirmed. For code 28230, the operative report does not support this procedure was performed in an unrelated anatomical area and would be inclusive to code 28725 already covered. For code 20902, the operative report describes bone was harvested from calcaneus and incision was closed with 3-0 bylon suture. Medicare billing criteria for these codes are not met.

We looked at this coder'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 surgical services provided to the enrollee on September 16, 2020 and billed under codes 27695, 28230, and 20902.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hemorrhoid removal provided on June 25, 2021.

You asked the Plan to waive the copayment for the hemorrhoid removal. You say that you do not want to pay the charge for a rubber band and five-minute appointment that did not work. The Plan denied your request. The Plan says you have been charged 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 $295 copayment for surgery or other services provided to you at an outpatient hospital.

You have been asked to pay a $295 copayment for the hemorrhoid removal. The hemorrhoid removal falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 hemorrhoid removal provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services provided to the enrollee on July 17, 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 Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the documentation supports a Physical Therapy Assistant performed services in the home, due to patient homebound. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) to report for therapy services performed in the home. Medicare billing criteria are not met.

We looked at this coder'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 therapy services provided to the enrollee on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site (D7953).  You asked the Plan to pre-approve a bone replacement graft. You say that the requested service is medically necessary. The Plan denied your request. The Plan says this service isn't covered under the enrollee's 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 pre-approve a bone replacement graft for ridge preservation - per site (D7953).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services rendered on May 20, 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 procedure code 99291 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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, there is no documentation of a critical care visit of 30-74 minutes. 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 critical care services rendered on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on January 29, 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 procedure codes 15734 and 15002 are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code  is 15734 is muscle, myocutaneous, or fasciocutaneous flap; trunk. The definition of code 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.  We find that CPT codes 15734 and 15002 are not supported in the medical record. Specifically, there is no documentation of muscle, myocutaneous, or a fasciocutaneous flap from the trunk to support code 15734. There is no documentation of surgical preparation or creation of a recipient site by excision of open wounds to support code 15002. 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 surgical services rendered on January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Omnipod (A9274).  You asked the Plan to pre-approve Omnipod. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B does not pay for infusion pumps other than those coded E0784. The request is for an infusion pump not coded E0784. Therefore, we decided that the Plan does not have to pre-approve treatment with Omnipod (A9274).   Benefits for Omnipod 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on February 4, 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 covered.

The Plan must follow Medicare rules. The rules say that TENS therapy is covered for chronic low back pain (CLBP) that meets specific criteria. 

We looked at the file and Medicare rules. The records show that the TENS therapy was not performed for CLBP but for leg pain. 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 transcutaneous electrical nerve stimulation (TENS) therapy rendered on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99239 provided on date of service May 5, 2021.

You asked the Plan to pay for procedure code 99239. You say that you have provided medical records to substantiate the code billed. The Plan denied your request. The Plan says it has already paid for a hospital discharge day management code for this enrollee from this provider for date of service May 4, 2021.

The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management code is payable per patient per hospital stay. The records show that this provider already billed (and was paid for) a hospital discharge day code in claim 820211250221302. Because one of these codes has already been paid, the code billed for date of service May 5, 2021, is not payable. Therefore, we decided that the Plan does not have to pay for procedure code 99239 provided on date of service May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the bone replacement graft (D4263) and surgical implant placement (D6010).  You asked the Plan to pre-approve the bone replacement graft (D4263) and surgical implant placement (D6010). The Plan denied your request. The Plan says the 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 bone replacement graft (D4263) and surgical implant placement (D6010) are not among those covered under this benefit. Contact the Plan regarding the request for reimbursement for the other dates of services. Therefore, we decided that the Plan does not have to pre-approve the bone replacement graft (D4263) and surgical implant placement (D6010).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 14, 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 covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a cardiovascular risk assessment panel, 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 rendered on May 14, 2021.