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

We decided that the Plan does not have to pay for physician services provided to the enrollee from October 9,
2019, to October 30, 2019.
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 CMS website shows the enrollee was enrolled in hospice from July 12, 2019 through
January 09, 2020. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using
the proper modifiers, for services rendered.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee from October 9, 2019, to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code95941.You asked the Plan to pay for code 95941. 

You say that this claim should be paid.The Plan denied your request. The Plan says while a portion of this claim was paid, code 95941 has a status code indicator of "I" and is not payable on Medicare claims.Medicare uses another code for this type of service. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status indicator of "I" and is excluded from payment on Medicare claims. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee and billed under code 95941
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to providenon-emergency transportation (A0100) benefits.You asked the Plan to providenon-emergency transportation. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not a covered benefit.The Plan must followMedicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of non-emergency transportation have not been met.Therefore, we decided that the Plan does not have to providenon-emergency transportation (A0100) benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on June 29, 2020.
You asked the Plan to waive the copayment for vision care. You say that you disagree with 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 a $35 copayment for exams to diagnose and treat diseases of the eye, including annual glaucoma screenings for high risk members. The record shows that you received vision care to diagnose and treat diseases of the eye on June 29, 2020. Therefore, you are responsible to pay the $35 copayment.
You have been asked to pay a $35 copayment for vision care. Vision care falls within the vision 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 vision care provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99202)and mechanical traction therapy (97012) provided on June 1, 2020, through July 6, 2020.You asked the Plan to pay forthe office visit and mechanical traction therapy. You say that you would like reconsideration because you were told these serviceswould be covered.The Plan denied your request. The Plan says only manual manipulation of the spine is covered.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 records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit (99202) and mechanical traction therapy (97012) provided on June 1, 2020, through July 6, 2020.Your complaint about being given incorrect information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forpercutaneous vertebroplasty (22510) provided on July 21, 2020.You asked the Plan to pay forthe percutaneous vertebroplasty. You say that you would like reconsideration because the member had multiple services on the same date of service.The Plan denied your request. The Plan says a modifier was not billed on the claim to represent the services as separate and distinct.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 the percutaneousvertebroplasty has a bundled relationship with code 22513 and cannot be paid as billed. Additionally, this code was not billed with a modifier to represent that the services were separate and distinct. 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 forpercutaneous vertebroplasty (22510) provided on July 21, 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 the enrollee requires daily physician rounding, nursing care, and frequent lab monitoring.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer.

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 o fthe 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 physician reviewer found that the enrollee was treated at an acute care hospital (ACH) for COVID-19. The enrollee was then discharged to a LTACH prior to receiving authorization. At the time of transfer, the enrollee was not intubated/ventilated. While in the LTACH, the enrollee has been receiving rehab therapy services,and appears to be medically stable.The enrollee's care needs do not necessitate admission to a LTACH.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete lower denture (D5120).You asked the Plan to pre-approvecomplete lower denture. You say that the service is medically necessary.The Plan denied your request. The Plan says you have exhausted your maximum benefit for this service.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. You are allowed one complete denture per sixty (60) months.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. Records indicated you received a complete denture on October 21, 2019, this means you have exhausted you maximum benefit for this service.Therefore, we decided that the Plan does not have to pre-approvecomplete lower denture (D5120).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy you had at an ambulatory surgical center on July 15, 2020.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that you had been suffering chronic diarrhea since early in the year.  You didn't see a gastroenterologist to get this colonoscopy ordered until July.  You said that if you had been able to see a doctor sooner that perhaps thisprocedure wouldn't have been necessary.The Plan denied your request. The Plan says you were charged this copayment 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 $450 copayment for services at an ambulatory surgical center. You have been asked to pay a $450 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the services at an ambulatory surgical center benefit category. This copayment applies regardless of the reason for the procedure. 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 nothave to waive the copayment forthe diagnostic colonoscopy you had at an ambulatory surgical center on July 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF 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 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 based on the documentation provided, the health plan's denial should be upheld. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe periodic oral evaluation (D0120), intraoral -complete series (D0210), and prophylaxis services (D1110) provided on September 29, 2020, by an out-of-network (OON) provider.You asked the Plan to waive the cost share forthe periodic oral evaluation, intraoral -complete series, and prophylaxis services. You say that you were not aware that the provider had left the network.The Plan denied your request. The Plan says the cost share has applied correctly for this OON routine dental service.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 periodic oral evaluation, intraoral -complete series, and prophylaxis services when the services are medically necessary and reasonable. You have been asked to pay the difference between the amount billed and the total cost of the dental services as specified by the Plan's contract for services received OON. 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 cost share forthe periodic oral evaluation (D0120), intraoral -complete series (D0210), and prophylaxis services (D1110) provided on September 29, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean epidural injection with ultrasound guidance.You asked the Plan to pre-approveepidural with ultrasound guidance. You say that prompt pain relief is medically necessary, and the enrollee wants to use ultrasound guidance instead of fluoroscopic guidance to avoid any radiation hazards.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because fluoroscopic or CT guidance are the only validated imaging methods and there is no contraindication noted for use of acontrast medium.The Plan follows Medicare rules. Medicare rules state that fluoroscopy and CT are the only two validated imaging methods for epidural injections.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve epidural with ultrasound guidance. Our reviewer says that this request does not meet the Medicare criteria for coverage. Our physician reviewer found while ultrasound may guide placement of the needle, it does not eliminate the risk of intrathecal or intravascular injection of the steroid which has been well documented to cause embolic complications. Medicare rules specifically delineate the acceptable imaging guidance. This request does not meet the criteria and; therefore, is deemed not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural with ultrasound guidance have not been met.Therefore, we decided that the Plan does not have to pre-approvean epidural injection with ultrasound guidance.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forBLS emergency ambulance (A0429 QL) provided March 27, 2020.You asked the Plan to pay forthe ambulance service. You say that if the claim was filed with the QL modifier identifying that patient was pronounced dead after ambulance called then the service is payable.The Plan denied your request. The Plan says that this service is not covered under the plan benefits.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service. Our reviewer says that the requested items/services meets the Medicare criteria for coverage in this case. Our physician reviewer found the medical records provided validate the enrollee was pronounced dead after arrival but before the enrollee was loaded onboard ambulance (before or after arrival at the point-of-pickup), which was represented on the claim with an appropriate QL modifier, therefore this claim has met Medicare criteria and is payable.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 ambulance service have been met.Therefore, we decided that the Plan has to pay forBLS emergency ambulance (A0429 QL) provided March 27, 2020.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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the back brace you received on July 29, 2020.
You asked the Plan to reduce the coinsurance for the brace. You say that you were able to find this brace much cheaper online. You also stated that the brace didn't fit properly so there was no point in using it. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Medicare allowed amount for the brace you received is $1,003.79. However, the provider you received this brace from only charged $773.00 for the brace, so the coinsurance was based off of this lower billed 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the brace. The brace falls within the durable medical equipment 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 reduce the coinsurance for the back brace you received on July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam (D2140) for tooth # 19 provided.

You asked the Plan to pay for the dental service. You say that you would like to appeal this denied claim so it can be overturned. You also say that you are not sure what the dental office did.The Plan denied your request. The Plan says the amalgam is not listed as a covered service.

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 amalgam (D2140) for tooth # 19 provided.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to
be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The
enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's
condition does not meet Medicare criteria for IRF care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for an inpatient hospital stay provided.

You asked the Plan to waive the co payment for an inpatient hospital stay. You say that you disagree with 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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 co payment for days 1-5 for inpatient hospital care. 

You had an inpatient hospital stay. Therefore, you are responsible to pay a $375 co payment. $375 (co payment) x 2 (inpatient days) = $750.

You have been asked to pay the total co payment amount of $750 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 co payment for an inpatient hospital stay provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2740) for tooth # 11, the post and core in addition to a crown (D2954), and the core build up (D2950) provided from July 21, 2020 to July 22, 2020.
You asked the Plan to reimburse you for the crown, post and core in addition to a crown, and core build up. You say that you were told the cleaning would only cost $110, not $202. You say that your second crown was fine when you walked into the office. You say that the dentist hit it when drilling the other tooth. You say that you should not be charged for the accident. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that post and core in addition to a crown is not listed as a covered service. The Plan says that 1 crown per calendar year is covered. The Plan also says that the frequency limit has been exceeded.
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 core build up and post and core in addition to a crown are not among those covered under this benefit. Additionally, the frequency limit of 1 crown per calendar year has been exceeded. The record shows that the Plan paid for 1 crown that you received
on this date of service, thus exhausting the benefit. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740) for tooth # 11, the post and core in addition to a crown (D2954), and the core build up (D2950) provided from July 21, 2020 to July 22, 2020.
Your complaint about the having to pay for a crown because the dentist broke it by accident is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.