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

We decided that the Plan does not have to pay forthe anesthesia services rendered on September 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the enrollee was on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. OriginalMedicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on September 26, 2019. The services in question were provided beforethe end of that month.Therefore, we decided that the Plan does not have to pay forthe anesthesia services rendered on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation care from April 5, 2019 through April 12, 2019 provided to the enrollee.
You asked the Plan to waive the copayment for acute inpatient rehabilitation care. You say that you never left the facility and that you were hospitalized continuously. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Medicare hospital benefit periods do not apply for the inpatient hospital care benefit; hence, the cost-share applies each time the enrollee is admitted to the hospital. Additionally, claim review indicates that the enrollee received regular inpatient hospital care from March 28, 2019 to April 5, 2019 and were then transferred to inpatient rehab care from April 5, 2019 through April 12, 2019 at the same hospital. The enrollee's 2019 EOC clearly states that a transfer to a separate facility type (such as an Inpatient Rehabilitation Hospital or Long Term Care Hospital) is considered a new admission. This means that the enrollee has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when the enrollee enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for acute inpatient rehabilitation care from April 5, 2019 through April 12, 2019 provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the regadenoson injection provided on August 7, 2019.
You asked the Plan to waive the coinsurance for the injection. The Plan denied your request. The Plan says that this applied correctly per your plan benefits.
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 Medicare Part B Prescription Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B Prescription Drugs 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 regadenoson injection provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on September 16, 2019.You asked the Plan to pay forthe treatment of root canal obstruction. You say that this service was provided by a approved dentist. You also say that you do not understand why this was not covered under your plan.The Plan denied your request. The Plan says this service is not listed in the limitations and exclusions section of your EOC.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 forthe treatment of root canal obstruction (D3331) provided on September 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cystoscopy provided on October 29, 2019.You asked the Plan to waive the copayment forthe cystoscopy. You say that you were advised you did not have a copayment. You say that the copayment should be waived.The Plan denied your request. The Plan says the copayment 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 $400 copayment for outpatient surgery at an outpatient hospital facility.You have been asked to pay a $400 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe cystoscopy provided onOctober 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 18. 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 18. 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on January 9, 2018 through December 28, 2018.

You asked the Plan to pay for the services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim has not been filed within the allowable 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 rules also say that The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR 424.5.

The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can see this in the Medicare Program Integrity Manual Chapter 3 3.3.2.1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care, for the enrollee.You asked the Plan to pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care, for the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveMagnetic Resonance Angiography (MRA) of the brain (70544).You asked the Plan to pre-approve the MRA. You say that the MRA is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRAs are covered only when they are medically necessary. 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 MRA. Our reviewer says that rules for coverage have been met. Our physician reviewer found a previous CT of the head showed calcification of large vessels in the brain. The enrollee has had relevant symptoms. MRA of the head is appropriately ordered here to better assess cerebral vascular involvement.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 MRA have been met.Therefore, we decided that the Plan has to pre-approveMagnetic Resonance Angiography (MRA) of the brain (70544)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for X-rays of the Shoulder (73030) and spine (72050) performed July 27, 2019
You asked the Plan to waive the copayment for the X-rays. You say that the copayment should be waived because the accident was not your fault. The Plan denied your request. The Plan says the auto insurer did not pay any portion of the claim, and the plan was the primary payer, therefore the correct copayment was applied.
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 $50 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $50 copayment for the X-rays. The X-rays fall within the Outpatient Diagnostic Tests 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 X-rays of the Shoulder (73030) and spine (72050) performed July 27, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from July 5, 2019 through July 15, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on July 5, 2019 and discharged on July 15, 2019. The enrollee was asked to pay a $370 copayment per day from July 5, 2019 through July 9, 2019, days 1-5 of the enrollee's inpatient stay. There were no copayment charges from July 10, 2019, day 6 of the enrollee's inpatient hospital care until their day of discharge July 15, 2019. Per the enrollee's contract there is a $370 copayment per day required for days 1-5 each time the enrollee is admitted to the hospital. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from July 5, 2019 through July 15, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve consultation with an out of network (OON) orthopedic oncologist.
You asked the Plan to pre-approve the OON orthopedic oncology consult. You say that the enrollee needs this care to treat his medical condition. The Plan denied your request. The Plan says that although there are several orthopedists in-network, there is a lack of accessible oncologic orthopedists.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. The requested provider is OON with the Plan. We were able to confirm that the Plan does not have contract providers located within reasonable distance and travel time from the enrollee's home who can provide the requested services. Under Medicare rules, this means that contract providers of this specialty are not accessible to the enrollee. Therefore, we decided that the Plan has to pre-approve consultation with an out of network (OON) orthopedic oncologist.
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: 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 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 IRF admission is covered only when it is medically reasonable and necessary as described above.

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 the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a Physical Medicine and Rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on their current functional status and medical stability. The enrollee is cognitively impaired at baseline with Dementia and does not have endurance for an IRF level of therapies.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder arthroplasty (23472) and repair of ruptured musculotendinous cuff (23412) provided on July 29, 2019.
You asked the Plan to pay for the shoulder arthroplasty and repair of ruptured musculotendinous cuff. You say that CPT 23412 has a bundled relationship with primary procedure 23472 performed on July 29, 2019. NCCI rules indicate that a modifier may be appended to the code to unbundle the relationship of the two codes providing the documentation in the patient's medical record supports the use of the modifier. Modifier 59 was used, indicating that procedure 23412 was performed as a "different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual" who performed the primary procedure, 23472. The medical documentation does not support that this procedure meets the requirements needed to append modifier 59 to CPT 23412. Additionally, the description for CPT code 23412 was not included in the medical documentation. The Plan denied your request. The Plan says CPT codes 23472 and 23412 are not supported by the medical record.
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 23472 is arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)).
The CPT Code Manual definition of code 23412 is repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the shoulder arthroplasty and repair of ruptured musculotendinous cuff. Our reviewer says that the shoulder arthroplasty (23472) does not meet criteria for reimbursement consideration. There is not documentation to support that any substantial additional work was performed related to CPT code 23472. As a result, billed CPT 23472 AS 22 RT cannot be verified. Our reviewer found repair of ruptured musculotendinous cuff (23412) does not meet criteria for reimbursement consideration. 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 shoulder arthroplasty and repair of ruptured musculotendinous cuff have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder arthroplasty (23472) and repair of ruptured musculotendinous cuff (23412) provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 24, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you did not receive any services at the urgent care center and were told you would not be charged. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered urgently needed care visit. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you were examined at the urgent care visit.
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 urgent care visit provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Theraskin (Q4121x39) provided on July 16, 2019.
You asked the Plan to pay for the Theraskin. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of units 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. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Theraskin. Our reviewer says that the billing of 39 units of CPT Q4121 is not supported. Our reviewer found the documentation indicates that Theragraft was applied to a wound measuring 15 sq cm. There is no evidence that 39 sq cm of Theraskin were applied. 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 Theraskin have not been met. Therefore, we decided that the Plan does not have to pay for Theraskin (Q4121x39) provided on July 16, 2019.