Persius/hicric huggingface dataset:
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 you disagree with the denial. The Plan denied your
request. The Plan says the services are 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for osteomyelitis and had a transmetatarsal amputation of the foot. His medical problems are stable,
and he has no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. There is not a reasonable expectation that he will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 the acupuncture services (97810) provided on January 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because you were told by the Plan that these services would be covered. The Plan denied your request. The Plan says with limited exceptions, you must use network providers to get your medical care and services.
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 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 the acupuncture services (97810) provided on January 5, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the periodic oral evaluation (D0120), intraoral x-ray (D0220), dental cleaning (D1110) and extraction (D7140) provided on January 15, 2021 and January 26, 2021.

You asked the Plan to waive the copayment for the dental services. You say that you should be reimbursed the difference in cost between out-of-network and in-network providers because the dental providers in the Plan's network are too far away from you. The Plan denied your request. The Plan says there are network providers located within a reasonable distance according to Medicare standards in your area. The Plan also says that these claims applied correctly; the Plan has covered the full cost up to the allowed amount for these services, and you are responsible for the difference between this amount and what the out-of-network provider billed.

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. We checked the distance to your specific address with the addresses of providers supplied by the Plan and found that they were available within a Medicare-defined reasonable distance and travel time for your county. Longer distances and travel times are permissible when they are based on location (such as a rural area) and/or established and based on routine patterns of care.

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 the difference in cost if an out-of-network provider charges more than what the Plan allows for a service.

Documentation shows that the Plan has paid the full allowed amount for each of these services, and you are responsible for the difference in cost between this amount and the amount the provider billed. 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 periodic oral evaluation (D0120), intraoral x-ray (D0220), dental cleaning (D1110) and extraction (D7140) provided on January 15, 2021 and January 26, 2021.

Your complaint about a lack of close-by in-network providers and possible issues with how the Plan assesses travel time and distance to providers 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections of pegfilgrastim (a Medicare Part B drug) provided on June 23, 2020 and July 15, 2020.

You asked the Plan to waive the coinsurance for Part B drugs. You say that this was part of your cancer treatment and should have been included in the initial treatment. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are correct.

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 Part B drugs. The allowed amounts of these claims total $7,764.41, resulting in a total coinsurance amount of $1,552.88. 

You have been asked to pay 20% coinsurance for Part B drugs. Part B drugs 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 injections of pegfilgrastim (a Medicare Part B drug) provided on June 23, 2020 and July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care provided from September 14, 2020, to October 22, 2020.
You asked the Plan to waive the copayments for wound care. You say that you should not be responsible for the charges because your primary care physician failed to treat your wounds. 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 $15 copayment for each specialist visit. You received wound care from September 14, 2020, to October 22, 2020, for a total of 11 visits. Therefore, you are responsible to pay a $15 copayment per each visit. The total amount you owe is: $15 (copayments) x 11 (visits) = $165. You have been asked to pay the total copayment amount of $165 for wound care. Wound care falls within the physician/practitioner services, including doctor's office visits 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 copayments for wound care provided from September 14, 2020, to October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on November 17, 2020.

You asked the Plan to pay for nursing facility care. You say that the treatment received was medically necessary and the claim should be processed for payment. The Plan denied your request. The Plan says services were provided by an out-of-network provider without authorization.

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 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 nursing facility care provided by an out-of-network provider on November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815).
You asked the Plan to pre-approve the PET scan. You say that the PET scan is requested to determine if the cancer has spread from the prostate to the other parts such as the lymph nodes which are enlarged. The Plan denied your request. The Plan says PET is non-covered in initial treatment strategy for prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our physician reviewer found CT results indeterminate and bone scan negative. Treatment should be initialized prior to considering additional imaging based on the criteria. Therefore, this request for PET will be considered not medically necessary at this time. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99497) provided on December 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 99497 is part of an edit pair with procedure code 99220. Procedure code 99220 is a column one code, and procedure code 99497 is a column two code. Procedure code 99220 has also been billed on this claim, which means that procedure code 99497 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (99497) provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from November 5, 2020, to December 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided from November 5, 2020, to December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (CPT code L3960) provided to the enrollee on June 15, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. According to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician as required per CMS guidelines. In addition, the invoice and Proof of Delivery are not valid based on the indicated dates. Also, the provider is not a Medicare certified DME supplier and therefore not eligible to receive payment. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (CPT code L3960) provided to the enrollee on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem tablets.
You asked the Plan to pre-approve self-administered drug. You say that this drug needs approval as soon as possible. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem tablets.
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-rays provided on December 11, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-rays. You say that you would like these services to be covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have 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, comprehensive oral evaluation is limited to one procedure every three years and full mouth or panoramic x-rays are limited to one procedure every five years. The record shows that you received a comprehensive oral evaluation on May 20, 2019, and you received a panoramic x-ray on June 6, 2018, and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and panoramic x-rays provided on December 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 73620, HCPCS Q0092, HCPCS
R0070) provided to the enrollee on November 11, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this was not billed correctly.

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 73620:

Radiologic examination, foot

HCPCS Q0092:

Set-up portable x-ray equipment

HCPCS R0070:

Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or
location, one patient seen

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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found in this
case, CPT code is a diagnostic or x-ray service and has both a technical and professional component. HCPCS
Q0092 and HCPCS R0070 are technical component only codes. The place of service is billed as skilled nursing
facility, -31. However, the enrollee was in a nursing facility, -32. Therefore, these services were billed with the
incorrect place of service. The CPT code 73620 professional component was not billed with the -26
professional component modifier. Therefore, the requested codes cannot be recommended as submitted.

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 pay for radiology services (CPT 73620, HCPCS Q0092, HCPCS R0070) provided to the enrollee on
November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 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 physician services provided on November 12, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 17, 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. The rules say that Medicare will pay for procedure code 33274 when billed with modifier Q0. We looked at the file and Medicare rules. The file shows that procedure code 33274 (transcatheter removal of permanent leadless pacemaker) was not billed with the Q0 modifier required for payment. 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 surgical services rendered on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on June
29, 2020.
You asked the Plan to pay for the drug testing. 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.
We find that CPT code G0483 and 80307 is not supported in the medical record. Specifically, the place of
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of
service 81; however, the submitted medical documentation and/or claim form indicates that the specimen was
obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for
the drug testing coded G0483 and 80307 provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on December 15, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.
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 periodontal maintenance provided on December 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for YAG laser capsulotomy (66821) provided
November 20, 2020.
You asked the Plan to waive the copayment for the laser surgery. You say that you had laser surgery and
thought everything was covered by the plan. You thought your copay was $50. The Plan denied your request.
The Plan says this claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $225 for
each Medicare covered outpatient hospital facility visit or ambulatory surgical center visit.
You have been asked to pay $225 for the laser surgery. The laser surgery falls within the Outpatient surgery
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 YAG laser capsulotomy (66821)
provided November 20, 2020.