Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from
November 19, 2020 to January 17, 2021.

You asked the Plan to pay for these services. You say that these claims should be paid. The Plan denied your
request. The Plan says per the Medicare guidelines an expired HIPPS code 2BFKS and 2BFK1 was billed for
the claim billing period from November 19, 2020 through January 17, 2021. Therefore, as an invalid HIPPS
code was billed which is a required element for HH PPS claims, this payment cannot be made. In addition, the
required "Q" is absent from the claim.

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 claim submitted cannot be paid due
to an expired code and the omission of the required "Q" code. Medicare billing criteria are not met. Therefore,
we decided that the Plan does not have to pay for home health services provided to the enrollee from November
19, 2020 to January 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on April 26, 2021 from an outpatient hospital facility.

You asked the Plan to waive the copayment for the lab services. You say that you went to the doctor's office for an annual preventative physical, so you don't know why you are being charged. The Plan denied your request. The Plan says the annual physical does not include lab services. The Plan says that you were charged the lab 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 $45 copayment for lab services at an outpatient hospital facility.

You have been asked to pay a $45 copayment for the lab services. Your Evidence of Coverage says that any lab or diagnostic procedures that are ordered are not covered under the routine physical exam benefit and you pay your plan cost sharing amount for those services separately. 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 lab services you received on April 26, 2021 from an outpatient hospital facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular pathology procedure (81406) provided on November 5, 2020.

You asked the Plan to pay for a molecular pathology procedure. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that testing billed with code 81406 is considered medically necessary in patients with symptoms of Wilson's disease to guide therapeutic decision making. 

We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee had symptoms of Wilson's disease. Based on this information, we decided that Medicare rules for coverage of a molecular pathology procedure have not been met. Therefore, we decided that the Plan does not have to pay for a molecular pathology procedure (81406) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit you had with a gastroenterologist on March 2, 2021.

You asked the Plan to reduce the copayment for the gastroenterology visit. You say that you were under the impression that specialist visits were only a $30 copayment. You say that you did not receive your Annual Notice of Change. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it shipped the Annual Notice of Change to you on September 14, 2020.

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 specialist visits.

You have been asked to pay a $40 copayment for the gastroenterology 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 reduce the copayment for the office visit you had with a gastroenterologist on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for radiofrequency ablation provided on January 19, 2021.

You asked the Plan to pay for radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625). You say that the clinical clarifications submitted substantiate the appropriateness of the procedure. The Plan denied your request. The Plan says radiofrequency ablation of the sacroiliac joint is considered not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Radiofrequency ablation of the sacroiliac joint is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) (64625) have not been met. Therefore, we decided that the Plan does not have to pay for radiofrequency ablation provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis provided on March 16, 2021.

You asked the Plan to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (20611). You say that the plan should pay this claim. The Plan denied your request. The Plan says requests for medical notes were made but information to support medical necessity were not received.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. There are no medical records supporting medical necessity of te procedure. Based on this information, we decided that Medicare rules for coverage of arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (20611) have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder brace provided on March 1, 2021.

You asked the Plan to pay for the shoulder brace. You say that this was medically necessary. The Plan denied your request. The Plan says the provider of this brace is excluded by the Office of the Inspector General (OIG).

The Plan must follow Medicare rules. Medicare rules say that payment cannot be made for services provided by a supplier who is excluded from the Medicare program.

The documentation shows that the provider has been excluded from the Medicare program. Therefore, we decided that the Plan does not have to pay for the shoulder brace provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatments provided from October 19, 2020,
through March 24, 2021.

You asked the Plan to pay for the acupuncture treatments. You say that this should be covered due to the
benefit you received. The Plan denied your request. The Plan says you did not receive these services from the
correct type of provider.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. The Plan also covers additional acupuncture based on its contract.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the services rendered were not for CLBP meaning
they are not covered by Medicare. They are also not covered under your supplemental benefit as they were not
provided by a physician as required in the contract. Therefore, we decided that the Plan does not have to pay
for the acupuncture treatments provided from October 19, 2020, through March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided January 20, 2021 to March 20, 2021.

You asked the Plan to pay for the electronic shock unit. You say that please reprocess for payment. The Plan denied your request. The Plan says the date of service on the claim does not match 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 E0745 is neuromuscular stimulator, electronic shock unit 

We find that CPT code E0745 is not supported in the medical record. Specifically, the date of service on the claim does not match the medical record. A corrected claim needs to be submitted. Based on this information, we decided that Medicare rules for coverage of the electronic shock unit have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided January 20, 2021 to March 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
October 28, 2020.

You asked the Plan to pay for this service. 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 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 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 October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on February 26,
2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
cannot be verified.

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 99291 is "Critical care, evaluation and management of
the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not
show that 30-74 minutes of critical care services were provided on the date of service in question. 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 critical care services (99291) provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99306) provided March
18, 2021.

You asked the Plan to pay for the subsequent nursing facility care. You say that the medical records provided
support the necessity of the services in dispute. The Plan denied your request. The Plan says this provider does
not show as a Medicare certified provider. Modifier SA is listed as not covered or not payable by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care
(99306) provided March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation due to your medical conditions. The Plan denied your request. The Plan says that this benefit is limited to 12 one-way trips per calendar year.

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 a maximum of twelve (12) trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you the Plan maximum does not have to cover routine transportation of the benefit maximum of twelve (12) trips for routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 these services are medically necessary. The Plan denied your request. The Plan says that your care needs can be met in the skilled nursing facility setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for total knee replacement. Your
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0861,
E0955, E1007, E1012, E1028, E2311, E2313, E2361, E2377, E2603) for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee clearly meets the medical necessity
standards for a power wheelchair. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found there is no
evidence of a myopathy, congenital skeletal deformity, or a neurological condition.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair and accessories (K0861, E0955, E1007, E1012, E1028,
E2311, E2313, E2361, E2377, E2603) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services you received from January 1, 2021, to January 29, 2021.

You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you did not know that the Plan would stop paying for this service after 20 days or you would have asked to be discharged. 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 $0 copayment for days 1-20, a $184 copayment per day for days 21-57, and a $0 copayment for days 58-100 for skilled nursing facility services.

Records show that you were admitted to the nursing home on December 18, 2020. You were discharged on January 29, 2021, for a total of 42 days. As per your Evidence of Coverage, you were not charged a copayment for the first 20 days of your stay. For the remaining days (days 21-42), you were charged a copayment of $3864 (21 days x $184 = $3864). 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 skilled nursing facility services you received from January 1, 2021, to January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the transthoracic echocardiography (93306) provided on February 25, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $175 copayment for Medicare-covered radiological diagnostic services, including x-rays, performed in a physician's office or at a free standing facility (such as a radiology center or medical clinic).

You have been asked to pay a $175 copayment for the Medicare-covered radiological diagnostic service provided. 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 adjust the copayment for the transthoracic echocardiography (93306) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for pathology services provided on February 4, 2021.

You asked the Plan to waive the copayment for the pathology services. You say that you do not think you should have to pay this copayment. The Plan denied your request. The Plan says that this copayment was charged correctly.

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 enrollees must pay a $0 copayment for lab services and a $35 copayment for specialist visits. 

The Plan says you must pay a $35 copayment for the pathology services. We do not agree. Pathology services are typically lab services. The Plan has failed to provide any records showing the specific pathology services that were provided or any bills or claims that show which specific procedure codes the pathologist billed. Furthermore, the Evidence of Coverage states that in order for the specialist copayment to apply, you have to have had a specialist visit. There is no evidence in the file that you ever visited this pathologist. In addition, there is nothing in the Evidence of Coverage section for physician services that indicates that pathology services would be considered part of the 'specialist' services copayment structure. It is more reasonable for you to expect that a lab copayment for pathology services would apply, not a specialist copayment. According to your Evidence of Coverage, you cannot be asked to pay more than a $0 copayment for lab services. Therefore, we decided that the Plan has to waive the copayment for pathology services provided on February 4, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.