Persius/hicric huggingface dataset:
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. You say that these services are medically necessary. The Plan denied your request. The Plan says that you could have the care you need at home.  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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Indomethacin, provided on March 5, 2021.  You asked the Plan to pay for the Indomethacin. You say that the drug should be covered. The Plan denied your request. The Plan says this is a self-administered drug.  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 pay for the Indomethacin, provided on March 5, 2021.   Benefits for the Indomethacin 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on August 17, 2020.   You asked the Plan to pay for the occupational therapy services. You say that the medical records required to reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support the code billed.  The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on November 27, 2020, through November 28, 2020.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  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 $300 copay per admission for inpatient hospital care.   You have been asked to pay a $300 copay per admi eans 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 inpatient hospital care provided on November 27, 2020, through November 28, 2020.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on April 26, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 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 an $85 copayment for emergency care.     You have been asked to pay an $85 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 April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae (CPT code 65865-59) provided to the enrollee on May 5, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Based on this information, we decided that Medicare rules for coverage of the services have not been met. CPT code 65865-59 79 LT (1 Unit) remains not supported. This code is included in Current Procedural Terminology (CPT) 66984 and 65820; therefore, it cannot be separately reimbursed. The documents received do not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. Therefore, we decided that the Plan does not have to pay for severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae (CPT code 65865-59) provided to the enrollee on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture (D0367), implant removal (D6100), and bone replacement graft for ridge preservation (D7953), provided on May 27, 2021 and June 4, 2021.  You asked the Plan to pay for the cone beam CT capture, implant removal, and bone replacement graft. You say that the services should be covered. The Plan denied your request. The Plan says these 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 requested items or services are not among those covered under this benefit. Specifically, these services are not listed in the Plan's benefit chart. This means they are not covered. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture (D0367), implant removal (D6100), and bone replacement graft for ridge preservation (D7953), provided on May 27, 2021 and June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) (CPT code 0376T) provided to the enrollee on January 14, 2021.  You asked the Plan to pay for the services. You say that you have revised and corrected the diagnosis code to have reconsidered and paid. The Plan denied your request. The Plan says the service is not covered.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Code 0191T for insertion of glaucoma drainage device has previously been approved/paid. Insertion of an anterior segment aqueous drainage device, code 0376T, as an additional device is considered not covered by Medicare and is excluded from coverage. Therefore, we decided that the Plan does not have to pay for insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) (CPT code 0376T) provided to the enrollee on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (CPT code G0453) provided to the enrollee on December 19, 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 services are not supported by the records.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    CPT code G0453-59 (5 Units) remains not supported. This code is included in CPT 95940; therefore, it cannot be separately reimbursed. The documents received do not support that the procedure or service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not supported. In addition, as per Centers for Medicare & Medicaid Services (CMS) guideline a physician shall not report 95940 and G0453 procedures for the same time period. If the two procedures are reported for the same date of service for the same patient, the time period for each procedure must be distinct and not overlapping with the time period for the other procedure. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (CPT code G0453) provided to the enrollee on December 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic massages and manual therapy chiropractic services provided to from July 1, 2020 to August 25, 2020.   You asked the Plan to pay for these services. You say that these services were medically necessary and should be covered by the Plan. The Plan denied your request.  The Plan says you self-referred out of network and the services provided are not covered by Medicare when rendered in a chiropractic office.   The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules also say that Plans can required enrollees to use network providers and to get prior authorization for services in and out of network. The Plan contract says that chiropractic services require referral and prior authorization. The records show you self-referred to this provider. These services were not authorized by the Plan. The services provided were not manual manipulation of the spine. Physical and massage therapy services provided in a chiropractic office are not covered by Medicare. Massage therapy services are not covered by Medicare in any setting. Therefore, we decided that the Plan does not have to pay for therapeutic massages and therapy services provided to from July 1, 2020 to August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the esophagogastroduodenoscopy rendered on May 17, 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 43249 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 43249 is esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter).  We find that CPT code 43249 is not supported in the medical record. Specifically, there is no documentation of a flexible transoral esophagogastroduodenoscopy. 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 esophagogastroduodenoscopy rendered on May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (CPT code(s): 95940, 95868-TC, 95861-TC, 95938-TC, 95927-TC) provided to the enrollee on April 29, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The Plan has already paid for these services as part of the payment to the facility. Facility charges include the technical component of intraoperative neurophysiology monitoring services. Billing these services separately together represents a duplication of effort and an overlap of services. The Plan states they will pay the physician or other non-facility provider for only the professional component of the services when performed outside the office. 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 pay for the services (CPT code(s): 95940, 95868-TC, 95861-TC, 95938-TC, 95927-TC) provided to the enrollee on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing provided on May 11, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered for CxBladder testing.   We looked at the file and Medicare rules. The requested CxBladder testing was billed with code 0013M. Code 0013M is not covered for CxBladder testing. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the walk boot (L4386), provided on January 26, 2021.  You asked the Plan to waive the coinsurance for the walk boot. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.    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 20% coinsurance for Prosthetic devices and related supplies.   You have been asked to pay a 20% coinsurance for the walk boot. This item falls within the Prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the walk boot (L4386), provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 11, 2021.  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 the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the partial dentures. We decided that the Plan does not have to pre-approve periodontal maintenance.
You asked the Plan to pre-approve the partial dentures. You say that your gum pockets are very deep. You say that you need a deep cleaning. You also say that you are missing teeth which causes you to grind your teeth at night. You also say that you do not want to lose anymore teeth. The Plan denied your request. The Plan says that the provided documentation does not show that the enrollee is missing 1 or more front teeth, or less than 8 teeth that are biting against each other.
We decided that the Plan has to pre-approve the partial dentures.
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 partial dentures when the services are medically necessary and reasonable. 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 partial dentures. Our reviewer says that the partial dentures with flexible bast are medically necessary. Our physician reviewer found replacement of these teeth would give the patient adequate bilateral occlusal function and prevent tipping of the teeth adjacent into the edentulous spaces. Therefore, the reviewer found that the requested partial dentures are medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the partial dentures have been met. Therefore, we decided that the Plan has to pre-approve the partial dentures.
We also decided that the Plan does not have to pre-approve periodontal maintenance.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance have not been met. Specifically, periodontal maintenance is not listed as a covered service. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the adjustable elbow device (E1800), provided on May 18, 2021.  You asked the Plan to waive the coinsurance for the adjustable elbow device. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  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 20% coinsurance for durable medical equipment (DME) and related supplies.   You have been asked to pay a 20% coinsurance for the adjustable elbow device. This item falls within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the adjustable elbow device (E1800), provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic testing services (CPT code(s): 95861, 95939, 95938, 95868) provided to the enrollee on April 15, 2021.  You asked the Plan to pay for the diagnostic testing services. You say that you have received authorization for the services. The Plan denied your request. The Plan says they consider charges made for the services of a health care provider who is not recognized as a legally qualified physician only when ALL of the following criteria are met: The non-recognized provider is employed by and working under the direct supervision of a recognized hospital, a health care facility* or a legally qualified physician.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information we determined that Medicare coverage criteria for the diagnostic testing services have not been met. Specifically, the record indicates that the enrollee had cervical fusion surgery in a facility on the billed date of service. The CPT codes at issue were billed with the technical component (TC) modifier indicating that they represent the technical components of these services.  Payments for technical components are included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the diagnostic testing services (CPT code(s): 95861, 95939, 95938, 95868) provided to the enrollee on April 15, 2021.