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

We decided that the Plan does not have to pay for the inpatient hospital services rendered from December 16, 2020 to December 18, 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 submitted records do not support the billing of DRG 280 and diagnosis code I47.2.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with DRG 280 and diagnosis code I47.2 (ventricular tachycardia). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 280 and diagnosis code I47.2. Our physician reviewer found the enrollee had a history of hypertension and a recent COVID-19 infection. He had rapid atrial fibrillation and was admitted to telemetry. He was evaluated by Cardiology and underwent a transthoracic echocardiogram and cardioversion. The records do not document a diagnosis of acute systolic (congestive) heart failure. The documentation does not accurately reflect the diagnosis of acute systolic (congestive) heart failure. The records do not support the billed DRG and diagnosis code. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from December 16, 2020 to December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require transfer.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that you are currently undergoing treatment at an acute care hospital (ACH) following bypass surgery. You were intubated/ventilated and subsequently received a tracheotomy. You remain on a ventilator. There is no evidence that you require services that are not currently available at the ACH where you are currently receiving care. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to an LTACH.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 13, 2021.

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 must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid. 

In this case, the MUE for CPT code 86077 and 86077-59 is 1. You billed 2 units of this code, exceeding the MUE. 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 laboratory services rendered on January 13, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the eye exam, ophthalmic ultrasound and bevacizumab injection provided on April 7, 2021.

You asked the Plan to waive the cost for the eye exam, ophthalmic ultrasound and bevacizumab injection. You say that you had an emergency situation and had no alternative but to seek medical assistance from an out-of-network doctor. You say that all visits to this doctor should be considered in-network. The Plan denied your request. The Plan says the claim reprocessed to only apply one $45 copayment and 20% coinsurance for the injection.

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 services for the diagnosis and treatment of diseases and injuries of the eye, $45 copayment for diagnostic procedures and tests from an in-network provider and 20% coinsurance for chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B from an in-network provider. 

You have been asked to pay a $40 copayment for the eye exam. You have been asked to pay $5 for the ophthalmic ultrasound, which is less than the standard $45 copayment. You have also been asked to pay $14.50, which is 20% of the allowed amount for the bevacizumab injection. The allowed amount is $72.51 (20% x $72.51 = $14.50). The total amount you owe is $59.50 ($40 + $5 + $14.50 = $59.50).

The eye exam falls within the "Vision care" benefit category. The ophthalmic ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The bevacizumab injection 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 cost for the eye exam, ophthalmic ultrasound and bevacizumab injection provided on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the computed tomography (CT) scan of the thorax provided February 25, 2021.

You asked the Plan to waive the cost share for the CT scan of the thorax. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the coinsurance has processed 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 20% coinsurance for outpatient diagnostic tests.

You have been asked to pay a total cost share of $37.50 for the CT scan of the thorax ($187.48 Medicare-allowed amount x 20% coinsurance). This service falls within the outpatient diagnostic tests 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 cost share for the computed tomography (CT) scan of the thorax provided February 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97530) provided on August 27,
2020.

You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration because
the services rendered were medically necessary. The Plan denied your request. The Plan says there is a more
appropriate CPT code for the services rendered.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We find that CPT code 97530 is not supported in the record. Specifically, the record indicates that these services were billed by an NP. An NP may not bill for services rendered by an OTA as they do not meet the qualifications of a therapist. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97530) provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oxygen concentrator (E1390) provided on January 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an oxygen concentrator. You say that you were told that this item would be covered. The Plan denied your request. The Plan says the use of an out-of-network provider was not authorized and this is available in-network.
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 an oxygen concentrator (E1390) provided on January 4, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the epoetin alfa rendered on December 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 with an incorrect diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. 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 epoetin alfa rendered on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visits for the evaluation and management of an established patient (99213) provided on January 18, 2021, and April 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the doctor's office visits. You say that when you signed up for the Plan, the sales representative told you that your doctors were fine. The Plan denied your request. The Plan says the services are not covered because they were rendered by an OON 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 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 office or other outpatient visits for the evaluation and management of an established patient (99213) provided on January 18, 2021, and April 19, 2021 by an out-of-network (OON) provider.
Your complaint about potentially being provided incorrect or incomplete information by a sales representative when signing up for the Plan 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: 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 inpatient rehabilitation is necessary for this enrollee to return to his prior level of function and safely return home. The Plan denied your request. The Plan says the enrollee's rehab needs are not complex, and the records show that it is not reasonable to expect that this enrollee would be able to participate in and fully benefit from a minimum of 15 hours of intensive therapy per week. The necessary services can be provided in another 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. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 27, 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. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on August 14, 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 procedure code 97110 is not supported.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on August 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on March 2, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you had a kidney stone procedure as an outpatient, and you do not understand self-administered drugs. You say that all drugs were administered by the medical group/team. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B.
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 pay for self-administered drugs provided on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 20, 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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid. 

In this case, the MUE for CPT codes 11042 and 11045 is 1. You billed 2 units of these codes, exceeding the MUE. 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 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
February 17, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. You say that you purchased the eyeglasses on March 1, 2021 while you were covered under a new HMO-POS Plan that offered a $400 annual allowance Wallet Benefit. The Plan denied your request. The Plan says the Plan paid the correct eyewear allowance based on the date of service of February 17, 2021 per the claim and your receipt.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid the correct amount based on the date of the claim and the receipt submitted for the Plan's annual allowance benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the cost-sharing for podiatry visit. We decided that the Plan does not have to waive the cost-sharing for podiatry visit.
You asked the Plan to waive the cost-sharing for podiatry visit. You say that you were not told that this service was subject to the deductible. The Plan says that the cost-sharing amount you are being charged is correct.
We decided that the Plan has to waive the deductible for podiatry visit.
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 the Plan deductible excludes specialist visits. A podiatrist is a type of specialist physician; therefore, a podiatry visit is excluded from the Plan deductible.
The Plan says that you must pay $71.28 deductible. Based on the Plan contract, however, the deductible does not apply to podiatry visit. Therefore, we decided that the Plan has to waive the deductible for podiatry visit.
We also decided that the Plan does not have to waive the cost-sharing for podiatry visit.
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 $35 copayment for podiatry visit. Therefore, we decided that the Plan does not have to waive the cost-sharing for podiatry visit.
Therefore, we decided that the Plan has to reduce your cost-sharing obligation for this claim from $71.28 deductible to $35 copayment.
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.
Please note that this decision is only regarding the podiatry visit provided on March 23, 2021. Please contact the plan regarding appeals for any other items or services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this is the appropriate level of care to
have a chance at regaining her quality of life. The Plan denied your request. The Plan says the enrollee is
receiving appropriate inpatient acute care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for heart
failure. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are
not currently available at the ACH where she is currently receiving care. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and bitewing x-rays provided on March 15, 2021.
You asked the Plan to pay for the prophylaxis and bitewing x-rays. You say that the flyer says a $0 copayment for the cleaning two times a year and a $15 copayment for a bitewing x-ray once a year. You say that the cost should be what the flyer says. The Plan denied your request. The Plan says the claim processed correctly.
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 contract says that you must pay 50% coinsurance for a cleaning and bitewing x-rays from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis and bitewing x-rays provided on March 15, 2021.