Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nasal hemorrhage control (30903) provided on November 4, 2019.
You asked the Plan to pay for the nasal hemorrhage control. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed service.
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 30903 is control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the nasal hemorrhage control. Our reviewer says that CPT code 30903 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method being performed on November 4, 2019, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nasal hemorrhage control have not been met. Therefore, we decided that the Plan does not have to pay for nasal hemorrhage control (30903) provided on November 4, 2019.
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 additional trips for dialysis treatment. The Plan denied your request. The Plan says the requested services are not a covered benefit. 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 30 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that once you have used your 30 plan covered one-way transportation trips, you will have exhausted the Plan maximum benefit for coverage of 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 waive the copayment for an inpatient hospital stay from September 6, 2018 to September 12, 2018.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford 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 $290 copayment each day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from September 6, 2018 to September 12, 2018. Therefore, you are responsible to pay a $290 copayment for days 1-6 (September 6, 2018 to September 11, 2018). $290 (copayment) x 6 (inpatient days) = $1,740.00.You have been asked to pay the total copayment amount of $1,740.00 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 copayment for an inpatient hospital stay from September 6, 2018 to September 12, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction, bone graft at time of implant placement, adjunctive dental procedure, interim abutment, surgical placement of implant body: endosteal implant, and panoramic x-ray provided on November 14, 2018 and March 27, 2019.You asked the Plan to pay forthe extraction, bone graft, adjunctive dental procedure, interim abutment, endosteal implant, and panoramic x-ray. The Plan denied your request. The Plan says you had already received the maximum amount of coverage allowed for these services. The Plan also says that you did not call to verify your benefits prior to receiving the services.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 2018 EOC clearly states that you have a $1,000 allowance every year for non-Medicare covered preventive and comprehensive dental services, and the 2019 EOC clearly states that you have a $200 Medicare-covered dental services allowance every year for non-Medicare covered preventive and comprehensive dental services. Both contracts also state that after your annual maximum benefit has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the 2018 and 2019 annual maximum benefits on March 16, 2018 and February 27, 2019 and your 2018 and 2019 annual maximum benefits had been exhausted.Therefore, we decided that the Plan does not have to pay forthe extraction, bone graft at time of implant placement, adjunctive dental procedure, interim abutment, surgical placement of implant body: endosteal implant, and panoramic x-ray provided on November 14, 2018 and March 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 6, 2019 to March 28, 2019.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 6, 2019 to March 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean osteogenesis stimulator (E0747).You asked the Plan to pre-approvean osteogenesis stimulator. You say that the item is necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteriahas not been met.The Plan follows Medicare rules. Medicare rules say that noninvasive stimulator devices are covered when specific criteria are met.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 an osteogenesis stimulator. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee has a 5th metatarsal fracture, which can be confirmed as having been present on February 23, 2020. There is no documentation that after ninety days of treatment (May 23, 2020 or later), the fracture has not healed. Therefore, the coverage criteria for the requested bone stimulator are not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an osteogenesis stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvean osteogenesis stimulator (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter placement (36245) provided on November 15, 2019.
You asked the Plan to pay for the catheter placement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records submitted did not support the billed service.
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 36245 is selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the catheter placement. Our reviewer says that CPT code 36245 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medial records submitted do not include documentation of a selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family being performed on November 15, 2019, therefore the service cannot be verified We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for catheter placement (36245) provided on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services (99233) provided on December 7, 2019
and December 8, 2019.
You asked the Plan to pay for the hospital services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Medicare guidelines say that ICD-10-CM has a coding convention
that requires the underlying condition be sequenced first, followed by the manifestation. In this case, J91.8 is a
manifestation code and cannot be used as the primary or first-listed diagnosis code on the claim. Based on this
information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore,
we decided that the Plan does not have to pay for the hospital services (99233) provided on December 7, 2019
and December 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), the retainer crowns (D6740) for teeth # 22 and 24, the pontic (D6245) for tooth # 23, and the extraction (D7140) for tooth # 23 provided on October 8, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered because the plan advised how much would be paid to the provider. The Plan denied your request. The Plan says the dentist is not in network at the location where the services were rendered. The record shows that you were advised that the provider in this case is not a network provider. You were also given an in network dentist that you could go to.
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 services you received are not covered when you receive them out of network. The record shows that you were advised by a plan representative that the provider in this case was not a network provider. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), the retainer crowns (D6740) for teeth # 22 and 24, the pontic (D6245) for tooth # 23, and the extraction (D7140) for tooth # 23 provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home services provided on November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for rest home services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 has network providers available who can provide 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 rest home services provided on November 7, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve an advanced leg pump device for the enrollee.You asked the Plan to pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plan says there is no documentation of a trial of a basic pump.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 pre-approve the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal physical exam findings of lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique characteristics that would indicate the requested pump over a standard pump. There is no documentation of a trial and failure of a standard pump. 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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvean advanced leg pump device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided on December 4, 2019 and December 6, 2019.
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the chiropractic treatment. 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 chiropractic treatment provided on December 4, 2019 and December 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora 3D CT scan provided on February 3, 2020.You asked the Plan to waive the copayment for a 3D CT scan. You say that you thought that you would only owe a $50 copayment.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 $175 copayment for diagnostic imaging. You have been asked to pay a $175 copayment for a 3D CT scan. A 3D CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a 3D CT scan provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care (99225) provided on April 30, 2019.
You asked the Plan to pay for the subsequent observation care. You say that you would like reconsideration because you rendered subsequent care. The Plan denied your request. The Plan says the number of days or units of service exceeds our acceptable maximum.
The Plan must follow Medicare rules. Medicare rules say that all other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent observation care have not been met. Specifically, the record indicates that an observation care code has already been allowed for the same date of service. Therefore, we decided that the Plan does not have to pay for subsequent observation care (99225) provided on April 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from December 23, 2019 to December 28, 2019.
You asked the Plan to waive the copayment. You say that the copayment should be waived as within one hour of being discharged home from the hospital, you collapsed, and were re-admitted for a blood transfusion and IV antibiotic treatment. The Plan denied your request. The Plan says the copayment has been applied correctly to the inpatient hospital care 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 $335 copayment per day, for days 1-5 of each hospital admission. You have been asked to pay a $1,340 copayment ($335 x 4) for inpatient hospital care. 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 inpatient hospital care provided December 23, 2019 to December 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99217) provided on July 27, 2018.
You asked the Plan to pay for discharge day management. You say that you did not receive information from the facility you needed to file this claim timely. The Plan denied your request. The Plan says claims must be filed within one year of the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for discharge day management was not filed until November 11, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for discharge day management (99217) provided on July 27, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to the provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says a tertiary provider or non-preferred provider is not approved when services can be done
safely with preferred network.
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 pre-approve the referral. Our reviewer says that the
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is not a reasonable medical reason to use the highly specialized tertiary level of care at this point in
time. You have a history of chronic low back pain and degenerative scoliosis. You have previously been seen
by one neurosurgeon who recommended against surgery (as it could worsen rather than improve her condition).
There is not otherwise an indication that other available options in the network have been exhausted. Nor is it
clear from the notes provided that you are an amenable candidate to surgical intervention (it should be noted
that surgery for this condition is known to have relatively high occurrences of complications so there is a
risk/benefit ration which must be strongly considered). Surgical correction of adult onset scoliosis does not
necessarily require a tertiary level of care in and of itself. In as much, based on the medical documents
provided there was not a significantly complicated situation to otherwise necessitated provision of services in
the tertiary level of care at this time. Such a consult would otherwise appear to be for the primary convenience
of yourself, and thus not eligible 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 the referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve a tertiary-level referral to the provider.