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

We decided that the Plan does not have to waive the copayment for chiropractic manipulative treatments
provided from July 13, 2020, through August 4, 2020.

You asked the Plan to waive the copayment for chiropractic manipulative treatments. You say that according to
the Plan all primary care and behavioral health medical service charges are being waived through December
31, 2020. You say that you are paying for medical services that are not warranted. The Plan denied your
request. The Plan says the copayments 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
copayment for Medicare covered chiropractic services at an in-network specialist's office.

You have been asked to pay a $20 copayment for each chiropractic manipulative treatment. The total amount
you owe is $80 ($20/treatment x 4 treatments = $80). Chiropractic manipulative treatments fall within the
"Chiropractic services" benefit category. The Plan says that only costs for primary care visits, behavioral health
visits and telehealth visits are being waived. 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 chiropractic
manipulative treatments provided from July 13, 2020, through August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain rendered on November 5, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that inpatient claims must be billed with POS code 21. 

We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue and the claim was not billed with the required POS code 21. 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 magnetic resonance imaging (MRI) of the brain rendered on November 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physical therapy. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the services being requested.

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 physical therapy to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on August 28, 2020.

You asked the Plan to pay for a lumbar-sacral orthosis. You say that this should be covered. The Plan denied your request. The Plan says the prescribing physician never saw the enrollee.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) fixed partial denture sectioning (D9120) surgical removal of erupted tooth, teeth 19, 31 (D7210x2) provided August 18, 2020.

You asked the Plan to pay for the dental services. You say that you spoke to a representative that confirmed this provider was in network. The same representative emailed you the list pf providers you could use, and this provider was included on that list. The Plan denied your request. The Plan says the requested service is not covered under the plan benefits and exceeds the benefit frequency limitation.

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 health plan contract says that 2 surgical removal of erupted tooth is covered every year. The plan has covered 2 surgical removals for this same date of service. The plan covers comprehensive oral exams once every 3 years. This service was previously provided on July 31, 2019. Fixed partial denture sectioning is not listed as a covered service, therefore is not covered. 

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 comprehensive oral exam (D0150) fixed partial denture sectioning (D9120) surgical removal of erupted tooth, teeth 19, 31 (D7210x2) provided August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent (67028) scanning computerized ophthalmic diagnostic imaging (92134) provided September 10, 2020.

You asked the Plan to pay for the diagnostic and injection services. You say that you request this denial be overturned and payment be made according to contract terms and governing law. The Plan denied your request. The Plan says until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1000 deductible. This is the amount you have to pay out-of-pocket before the plan will pay their share for your covered medical services. 

The item or service you asked the Plan to pay for falls within the benefit category deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 deductible. This cost sharing is a contractual obligation that had not been met at the time the diagnostic and injection services was received on September 10, 2020. Therefore, we decided that the Plan does not have to pay for intravitreal injection of a pharmacologic agent (67028) scanning computerized ophthalmic diagnostic imaging (92134) provided September 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services rendered on October 13, 2020.

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 you have used the full benefit limit.

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 up to $255 every year for supplemental dental benefits. 

We looked at the file and the Plan's rules. The file shows that the Plan applied the full $255 supplemental dental benefit as of October 13, 2020. Further reimbursement is not covered by Medicare or your supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the dental services rendered on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevating system.

You asked the Plan to pre-approve a power seat elevating system. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevating system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevating system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services coded 29882 provided on August 13, 2020.

You asked the Plan to pay for the arthroscopy 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. In this case, the CPT Code Manual definition of code 29882 is arthroscopy, knee, surgical; with meniscus repair (medial OR lateral). 

We find that CPT code 29882 is not supported in the medical record. Specifically, the operative report did not include documentation of a surgical knee arthroscopy with meniscus repair. Based on this information, we decided that Medicare rules for coverage of the arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy services coded 29882 provided on August 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient has no complex wound care or other SN need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility setting 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided to the enrollee from September 30, 2020 to October 7, 2020.

You asked the Plan to pay for the services. You say that payment should be allowed based on medical necessity and continuity of care. The Plan denied your request. The Plan says the enrollee was in a Part A skilled nursing facility (SNF) stay on the dates of service, and therefore the claims do not support the place of service 32 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. 

In this case, the CPT Code Manual definition of the denied codes is: 

CPT 99305: 

initial nursing facility visit, typically 35 minutes per day. 

CPT 11042: 

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less. +11045 - each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 

CPT 99308: 

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of low complexity. 

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records submitted indicate the enrollee was in a Part A skilled nursing facility (SNF) stay at the time the services were rendered; therefore these services are not eligible for reimbursement because they were submitted under place of service 32 instead of 31. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for wound care provided to the enrollee from September 30, 2020 to October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this will work as an alternative for surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99226) provided from August 31, 2020, to September 1, 2020.
You asked the Plan to pay for observation care. You say that the provider of these services is separate from the hospital. The Plan denied your request. The Plan says these services were billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. The record shows that the enrollee was a registered inpatient at the time of service, but these services were reported with POS code 22, not 21. Based on this information, we decided that Medicare rules for coverage of observation care have not been met. Therefore, we decided that the Plan does not have to pay for observation care (99226) provided from August 31, 2020, to September 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria have not been met.
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 24 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services provided during an
annual wellness visit (99214, G0439) provided June 12, 2020.
You asked the Plan to waive the copayment for the physician services provided during an annual wellness visit.
You say that you should not be charged a copayment for the annual wellness visit. The Plan denied your
request. The Plan says due to additional services were provided at the annual wellness visit and therefore a
copayment was applied for the physician services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The Plan contract says that there is no coinsurance, copayment or
deductible for the annual wellness visit and/or preventive physical exam each year. If you and your doctor
discuss a condition that requires additional services including but not limited to follow-up medical visits with
your primary care physician or specialists and/or certain lab or diagnostic services, you may incur cost-sharing
charges for those services. It also says that you must pay a $15 copayment for Physician/Practitioner services,
including doctor's office visits with a primary care physician.
You have been asked to pay a $15 copayment for the physician services provided during an annual wellness
visit. These additional services fall within the Physician/Practitioner services, including doctor's office visits
with a primary care physician 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
physician services provided during an annual wellness visit (99214, G0439) provided June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the basic metabolic panel services coded 80048, the travel
allowance services coded P9604, and the collection of venous blood by venipuncture or urine sample services
coded G0471 provided on August 6, 2020.
You asked the Plan to pay for the basic metabolic panel services, the travel allowance services, and the
collection of venous blood by venipuncture or urine sample 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 payable.
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 80048, P9604, and G0471 are not supported in the medical record. Specifically, these
codes have a status code of X. A status code of I means that these services are not in the statutory definition of
"physician services" for fee schedule payment purposes. No RVUS or payment amounts are shown for these
codes, and no payment may be made under the physician fee schedule. Based on this information, we decided
that Medicare rules for coverage of the basic metabolic panel services, the travel allowance services, and the
collection of venous blood by venipuncture or urine sample services have not been met. Therefore, we decided
that the Plan does not have to pay for the basic metabolic panel services coded 80048, the travel allowance
services coded P9604, and the collection of venous blood by venipuncture or urine sample services coded
G0471 provided on August 6, 2020.