Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says that the services provided are with Medicare's 2 midnight rule for
observation.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found because this is based upon the physician's expectation, as opposed to a retroactive
determination based on the actual length of stay, unforeseen circumstances that result in a shorter stay than the
physician's reasonable expectation may still result in a hospitalization that is appropriately considered
inpatient. If the stay ultimately is shorter than two midnights, consideration of "rare and unusual"
circumstances regarding the care which are well-documented in the medical records will be given.

In this case, the reasoned judgement of both the emergency room and admitting physician was that the patient
required in-patient services. The fact that the stay was less than two midnights was an unforeseen circumstance.
Therefore, the admission satisfied the requirement of a prospective expectation and the requested service is
recommended for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

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 services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home services coded R0070.

You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.

We find that CPT code R0070 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) Indicator of 3. This component represents the transportation of the equipment to the patient. Establish local RVUs for the transportation R codes based on Medicare Administrative Contractor (MAC) knowledge of the nature of the service furnished. The MACs shall allow only a single transportation payment for each trip the portable x-ray supplier makes to a particular location. When more than one patient is x-rayed at the same location, e.g., a nursing home, prorate the single fee schedule transportation payment among all patients (Medicare Parts A and B, and non-Medicare) receiving the portable x-ray services during that trip, regardless of their insurance status. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home services coded R0070.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment (L3984) and sales tax (S9999).

You asked the Plan to pay for wrist brace and sales tax. You say that the item should be covered at 50% for being out of network. The Plan denied your request. The Plan says the provider is not under contract with the health plan and is not certified with Medicare and sales tax is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that you must receive services from a provider or supplier enrolled in Medicare to be eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wrist brace and sales tax have not been met. Specifically, you received this item from a provider that is not enrolled with Medicare. Also, sales tax and shipping charges are not separately payable by Medicare. This means the items are not covered. Therefore, we decided that the Plan does not have to pay for Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment (L3984) and sales tax (S9999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a central venous catheter placement.

You asked the Plan to waive the copayment for a central venous catheter placement. You say that the charges are fraudulent. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

The medical records show that you received a central venous catheter placement. A central venous catheter placement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment.

You have been asked to pay a $325 copayment for a central venous catheter placement. A central venous catheter placement 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 for a central venous catheter placement provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services.

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 services are not separately payable.

The Plan must follow Medicare rules. The rules say that the SNF must submit ALL Medicare claims for ALL the services that its residents receive under Part A.

We looked at the file and Medicare rules. The file shows that the services were rendered to the enrollee in a SNF. Payment for these services is included in the SNF consolidated billing. 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 mobile x-ray services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that you depend on the hospital staff to verify eligibility and obtain prior authorization. You do not feel the provider should be held liable for the hospital staff's failure to get prior authorization. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The services were not urgent and prior authorization was not obtained. The provider or the facility are responsible for verifying the enrollee's eligibility and obtaining prior 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 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 nursing facility care (99309) provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided .You asked the Plan to pay forthe dental service. You say that this was an emergency situation. You say that you developed an infection which caused you a great deal of pain. You say that this required an assessment and x-ray. You say that your dentist scheduled a root canal as soon as possible. You also say that if the infection got to your hips that had been replaced, it would be catastrophic.The Plan denied your request. The Plan says 1 oral evaluation is covered per calendar year. The Plan says that the frequency limit for this service has been exceeded. The Plan says there is a $50 office visit copayment. The Plan says that that the periapical x-ray is covered. The Plan also says that thecopayment was applied to the periapical x-ray.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 frequency limit for oral evaluations has been exceeded. The record shows that the Plan paid for an oral evaluation that you received. Additionally, there is a $50 office visit copayment which was applied to the periapical x-ray.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the periapical x-ray (D0220) provided .
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lightweight wheelchair and elevating leg rests (K0003 and K0195) provided .You asked the Plan to pay forthe lightweight wheelchair and elevating leg rests. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says payment for this durable medical equipment is included in the payment to the skilled nursing facility.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the lightweight wheelchair and elevating leg rests was used in a SNF or hospital. Payment for this service is included in the payment to the SNF and is the responsibility of the SNF to any vendor.Therefore, we decided that the Plan does not have to pay forthe lightweight wheelchair and elevating leg rests (K0003 and K0195) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services (11042, 99309) provided by an OON provider.

You asked the Plan to pay for OON wound care services. You say that these services were medically
necessary. The Plan denied your request. The Plan says these services were not authorized.

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
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the wound care services (11042, 99309).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (L0650).

You asked the Plan to pay for the back brace. You say that you would like reconsideration because the back brace is medically necessary. The Plan denied your request. The Plan says this provider did not present any medical records showing that the prescribing physician ever saw the member.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the back brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal an objective physical examination of the lumbar spine or the neuromuscular system. There is no evidence on a physical exam that indicates member's pain is reduced by restricting trunk mobility. There is no evidence of a recent injury or surgery to the spine or related soft tissues that requires the orthosis to facilitate healing. There is no evidence on an objective physical exam of weak or deformed spinal muscles.

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 back brace have not been met. Therefore, we decided that the Plan does not have to pay for the back brace (L0650).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 33986) provided .You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed code 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 33986 is "Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older".We asked our codingreviewer 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 use of CPT code 33986 is not supported by the records provided. Our codingreviewer found that the operative report did not include documentation of removal of central cannula by sternotomy or thoracotomy.  Therefore, this service cannot be confirmed.We looked at this coder'sreview, 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 forthe services (CPT 33986) provided .
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided .You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the services billedare not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., tocontrol for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not include definitive laboratory results for 22 or more drug classes to support this code billed. 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 forthe drug testing coded G0483 provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99213).

You asked the Plan to waive the copayment for the urgent care visit. You say that the copayment should be
waived. The Plan denied your request. The Plan says 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 $65
copayment for Urgent Care visits.

You have been asked to pay a $65 copayment for 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 an urgent care visit (99213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D4341, D5214, D5213).

You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says your dental benefit was exhausted at the time the service was provided.

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 coverage is limited to $2,000 a year. Any amount in excess of $2,000 is not covered. The record shows your dental services exceeded $2,000 at the time services were provided. Therefore, we decided that the Plan does not have to pay for dental services (D4341, D5214, D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora portable gaseous oxygen system (E0431) and oxygen concentrator (E1390) provided .You asked the Plan to waive the coinsurance fora portable gaseous oxygen system and oxygen concentrator. You say that you should not owe coinsurance for October because you had made numerous calls to the supplier requesting a pick-up of the equipment at issue.The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each Medicare-covered durable medical equipment item. You have been asked to pay $36.97, or 20% of the Medicare-allowed amount of $184.85, for a portable gaseous oxygen system and oxygen concentrator. Aportable gaseous oxygen system and oxygen concentrator fallwithin the "Durable medical equipment (DME) and related supplies" 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 fora portable gaseous oxygen system (E0431) and oxygen concentrator (E1390) provided .Your complaint about the supplier not picking up your DME items timely 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the enrollee is unable to afford the cost of Prolia with their assistance program.The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug, Zoledronic Acid. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.