Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH)
for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another setting, for example: acute
rehabilitation facility, skilled nursing facility, nursing, outpatient setting, or home care.

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 there is no documentation provided indicating medical necessity for LTACH
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan.

The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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. Therefore, we decided that the Plan
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve True Metrix glucose test strips.

You asked the Plan to pre-approve True Metrix glucose test strips. You say that the enrollee has been using this brand for years. The Plan denied your request. The Plan says this is not a preferred brand.

The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the durable medical equipment (DME) to only those preferred brands and manufacturers, as long as the conditions listed in the rules section are met, including that the MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME products or brands. 

We looked at the file and Medicare rules. The submitted records do not document medical reasoning why the enrollee requires the requested brand over either of the Plan preferred brands. Based on this information, we decided that Medicare rules for coverage of True Metrix glucose test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the Intracept procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says there are not enough studies on Intracept to show it is safe and effective.

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 the Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and report on referred slides prepared
elsewhere (CPT code 88321) provided to the enrollee on November 13, 2020.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the second unit is not covered because CPT code 88321 has an MUE of 1.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.

In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed two (2) units of
this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
service have not been met. Therefore, we decided that the Plan does not have to pay for the consultation and
report on referred slides prepared elsewhere (CPT code 88321) provided to the enrollee on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 21, 2020.
You asked the Plan to pay for the screening services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels.
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. We looked at the file and the rules. There are insufficient records to show that the ordered testing correlates any test result with given interventions. The screening services were requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), cleaning (D1110), prefabricated abutment (D6056) and abutment supported crown (D6058) provided on April 26, 2021, by an out-of-network dentist.
You asked the Plan to pay for the dental services. You say that these services should be covered, and you contacted one in-network dentist who never returned your call, so you used another provider. The Plan denied your request. The Plan says non-emergency, out-of-network dental care is not covered. There were several dental providers in the Plan's network who could have provided dental care.
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 periodic oral evaluation (D0120), cleaning (D1110), prefabricated abutment (D6056) and abutment supported crown (D6058) provided on April 26, 2021, by an out-of-network dentist.
Your complaint about dissatisfaction with your benefits/coverage is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 22, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the time limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services was not filed until March 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided May 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the periodontal maintenance. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered when provided OON.
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. The Plan covers the periodontal maintenance when the services are provided by a network provider. We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the periodontal maintenance have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided May 13, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intestine surgery services coded 49240, 44120, and
47500 provided on February 1, 2021.

You asked the Plan to pay for the intestine surgery services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT codes 49240, 44120, and 47500 are not supported in the medical record. Specifically, the
documentation does not include a detailed operative note to validate these codes. Based on this information, we
decided that Medicare rules for coverage of the intestine surgery services have not been met. Therefore, we
decided that the Plan does not have to pay for the intestine surgery services coded 49240, 44120, and 47500
provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound study provided on November 25, 2019.
You asked the Plan to pay for limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922). You say that you submitted the claim timely on November 30, 2019. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) was not filed until March 30, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ultrasound study provided on November 25, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on March 18, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that the Plan should pay this claim. The Plan denied your request. The Plan says a pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery in any setting.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for the pneumatic compression device (E0676) provided on March 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 14, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you had a reaction to the coronavirus vaccine and were told you would not owe anything. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gingivectomy or gingivoplasty (D4212 x 2), the 4-surface fillings (D2335 x 2), the 3-surface filling (D2332), the oral exam (D0120), and periodontal maintenance (D4910) provided from March 17, 2021, to April 1, 2021.

You asked the Plan to reimburse you for the dental services. You say that when you signed up for this plan you were advised that you could see any dentist. You say that you were not told that you needed to see a dentist that participated with Medicare. You also say that you would like these services to be covered as a one-time exception. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services performed by a provider that have opted out of Medicare.

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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the gingivectomy or gingivoplasty (D4212 x 2), the 4-surface fillings (D2335 x 2), the 3-surface filling (D2332), the oral exam (D0120), and periodontal maintenance (D4910) provided from March 17, 2021, to April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899).

You asked the Plan to pre-approve an Intracept procedure. 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 because the requested procedure 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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899).
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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for TENS, vasopneumatic device and vitamin injections provided on January 27, 2021.
You asked the Plan to pay for TENS, vasopneumatic device and vitamin injections. You say that the medical records support the medical necessity for the services. The Plan denied your request. The Plan says a TENS device including supplies is not a Medicare covered benefit with the available information. Pneumatic compression vasopneumatic devices can be covered in the home or other outpatient setting only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. Vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service.
The Plan must follow Medicare rules. Medicare rules say that that Medicare Part B 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 service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) 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. 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 this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot. Therefore, we decided that the Plan does not have to pay for TENS, vasopneumatic device and vitamin injections provided on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on May 15, 2021, and
May 17, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you have an extensive severe allergy
list, many of which are pain medications, which leaves you little choices for emergency room pain medications.
You also say that You cannot take any pain medication without nausea medication. The Plan denied your
request. The Plan says self-administered medications are not covered by Medicare.
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 pay for the self-administered drugs
provided on May 15, 2021, and May 17, 2021.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 6, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 6, 2021.