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

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the certification dated August 17, 2021, documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthesis to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a prosthesis. You say that the service is medically necessary. The Plan denied your request. The Plan says there are in-network providers who can perform this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous skeletal fixation of femoral fracture coded
as 27235 provided July 30, 2020.

You asked the Plan to pay for the percutaneous skeletal fixation of femoral fracture. You say that you would
like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim has
denied correctly.

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 27235 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
percutaneous skeletal fixation of femoral fracture have not been met. Therefore, we decided that the Plan does
not have to pay for the percutaneous skeletal fixation of femoral fracture coded as 27235 provided July 30,
2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital services provided January 14, 2021, to February 16, 2021.

You asked the Plan to pay for the acute inpatient hospital services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that these services were billed without Room and Board charges and a corrected claim is needed.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the denial has not been substantiated by the Plan to determine why they are not paying for the claim. Of note, the claim submitted does include Room and Board charges. No information was forwarded to support the assertion that there are no Room and Board charges reported on this claim. Therefore, we decided that the Plan has to pay for the acute inpatient hospital services provided January 14, 2021, to February 16, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and
mandibular interim partial denture (D5821) provided on January 12, 2021, and February 8, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and mandibular interim partial
denture. You say that you needed to see the dentist regarding your broken partial plate. You also say that your
partial was in need of replacement or it would cause a shift in your present teeth. The Plan denied your request.
The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the
date of service to verify benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation (D0140) and mandibular interim partial denture (D5821) provided on
January 12, 2021, and February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a spinal distraction device.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee needs this procedure to alleviate chronic low back pain. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.

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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous distraction devices remain experimental in spinal surgery. More research is needed to show safety and efficacy of these devices.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a spinal distraction device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on March 24, 2021.

You asked the Plan to pay for the imaging services. You say that the procedure was rendered in the appropriate
place of service. The Plan denied your request. The Plan says the claim was billed with an inappropriate place
of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We looked at the file and the rules. The claim shows the place of service for the x-ray was billed as an
outpatient service. However, the file shows that the enrollee was an inpatient at the time the services were
provided. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain coded as 70450 provided February 28, 2021.

You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code as required by Medicare.

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 have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain coded as 70450 provided February 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that the enrollee requires a long-term hospital stay and risks exposure to COVID-19 the longer they are in the hospital. The Plan denied your request. The Plan says the criteria for an LTACH are not met. The records show it is not very likely that the enrollee will require a stay of 25 days or more and need to see a doctor every day. The necessary services can be provided in a lower level of care, such as a skilled nursing facility.
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 pay for 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 that the enrollee appears to be improving and only requires short-term additional acute care services which can be safely provided at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility or at a lower level of care. Therefore, a request for transfer to an LTACH is not considered medically necessary at this time. Transfer to a lower level of care may be considered when treatment is completed.
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 pay for long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy services.

You asked the Plan to pre-approve massage therapy services. You say that you are in extreme pain. The Plan
denied your request. The Plan says massage therapy is not covered under Medicare or under your contract with
them.

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for frames and lenses provided on April 22, 2021.

You asked the Plan to pay for the frames and lenses. You say that you would like reconsideration because these
glasses were prescribed after cataract surgery. The Plan denied your request. The Plan says that the coinsurance
that has been applied is correct.

The rules say that Medicare will cover eyewear after cataract surgery.

We looked at the file and the rules. The Plan rules say that there is a $0 copayment for eyewear received after
cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the frames and
lenses have been met. Specifically, the Plan has verified that this eyewear was prescribed post cataract surgery.
Therefore, we decided that the Plan has to pay for frames and lenses provided on April 22, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation provided on April 9, 2021.
You asked the Plan to pay for the moderate sedation. You say that the attached reports support the level of
service and the claim should be reconsidered for processing. The Plan denied your request. The Plan says the
provider did not bill as required by Medicare coding regulations.
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 99153 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status.
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a
technical component only code. The technical component will not be paid to the physician when performed in a
facility setting. This means that payment for this service is the responsibility of the facility to any vendor.
Based on this information, we decided that Medicare rules for coverage of the moderate sedation have not been
met. Therefore, we decided that the Plan does not have to pay for the moderate sedation provided on April 9,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5213) and occlusal adjustment (D9951) provided on February 10, 2021.
You asked the Plan to pay for the maxillary partial denture and occlusal adjustment. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered under your 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 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 maxillary partial denture (D5213) and occlusal adjustment (D9951) provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673), provided on August 25, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says the enrollee used the equipment in the facility during and/or after surgery.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that a pneumatic compression device was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673), provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.

You asked the Plan to reimburse you for a health club membership. You say that with all that is going on, time just got away. The Plan denied your request. The Plan says you did not submit your reimbursement request within the required time frame.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture, and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. You pay all charges over $150 per calendar year. Reimbursement requests must be received by the Plan no later than March 31st of the following year. 

The Plan's rules for coverage of gym benefits have not been met because the reimbursement request was submitted outside of the coverage year. Therefore, we decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673), provided on July
8, 2020.

You asked the Plan to pay for [a pneumatic compression device. You say that the item was medically
necessary. The Plan denied your request. The Plan says the item was used in a hospital setting.

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 pneumatic compression device was used in a SNF or hospital. Therefore, we decided that
the Plan does not have to pay for a pneumatic compression device (E0673), provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #6.

You asked the Plan to pre-approve the crown. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service exceeds the benefit allowance.

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, crowns are limited to one per tooth per 60 months. The record shows that you received a crown (D2751) on tooth #6 on February 25, 2021 and your crowns benefit for tooth #6 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #6.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the hand ultrasound provided on January 2, 2020.

You asked the Plan to pay for the ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation (76881). You say that you would like the Plan to reconsider the corrected claim. 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 the ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation (76881) was not filed until May 25, 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 hand ultrasound provided on January 2, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition does not support this level of 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 the enrollee appears to be improving and only requires short-term additional acute care services that can be safely provided at the current facility. The enrollee does not require services at the LTACH that are not already available at the current 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. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.