Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) provided from September 12, 2020, to October 11, 2020.
You asked the Plan to pay for the SNF services. You say that on the dates of service in this case, the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care. The Plan denied your request. The Plan says the services provided to the enrollee are coverable under the Medicare Act.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) provided from September 12, 2020, to October 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair provided on January 22, 2020 to February 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item rendered is not medically necessary.
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 power wheelchair provided on January 22, 2020 to February 22, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the hospital should be responsible for this cost. The Plan denied your request. The Plan says you were formally admitted to the hospital for one inpatient day therefore the correct cost share 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 $225 copayment per day for days 1-6 for inpatient hospital care. You have been asked to pay a $225 copayment for one day for the inpatient hospital stay. This 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 the inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cardiovascular telemetry.

You asked the Plan to waive the deductible for the cardiovascular telemetry. You say that you were not told that the cardiologist and the company were out-of-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $975 deductible that applies towards diagnostic procedures and tests. 

The cardiovascular telemetry you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible that applies towards diagnostic procedures and tests. The record shows the cardiovascular telemetry is considered a diagnostic test that was provided by an out-of-network provider.

This cost sharing is a contractual obligation that had not been met at the time the cardiovascular telemetry. Therefore, we decided that the Plan does not have to waive the deductible for the cardiovascular telemetry.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (J3010, 00170) you received on August 4, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. As primary procedure, the extraction, is a Medicare non-covered service, the anesthesia services are also non-covered. Therefore, we decided that the Plan does not have to pay for the anesthesia services (J3010, 00170) you received on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wig purchased on November 26, 2019.
You asked the Plan to reimburse you for the wig. You say that you had a prescription for the wig. The Plan denied your request. The Plan says a cranial prosthesis is statutorily excluded.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to reimburse you for the wig purchased on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for the comprehensive metabolic panel, the lipid panel, the blood count, hemogram, and platelet count, the drug test, presumptive, the drug test, definitive, and the integral venipuncture.

You asked the Plan to waive the deductible and copayment for the laboratory services. You say that you were charged a different amount for these services in the past. The Plan denied your request. The Plan says the cost share amount you are responsible for is dependent upon the services billed until the deductible is met, and your cost share was correctly applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible for outpatient diagnostic tests and therapeutic services and supplies. 

The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible, as well as a $15 copayment once your deductible has been met, for outpatient diagnostic tests and therapeutic services and supplies. You had $202.05 remaining in your deductible. Once your deductible was met, you were required to pay a $15 copayment for the remaining outpatient diagnostic tests and therapeutic services and supplies. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the deductible and copayment for the comprehensive metabolic panel, the lipid panel, the blood count, hemogram, and platelet count, the drug test, presumptive, the drug test, definitive, and the integral venipuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair cushions provided on September 29, 2020.
You asked the Plan to pay for the wheelchair seat cushion and wheelchair back cushion. You say that the enrollee needs the wheelchair seat cushion and wheelchair back cushion. The Plan denied your request. The Plan says a claim for wheelchair back and seat cushions was paid on September 4, 2018.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that R. Crescio had wheelchair back and seat cushions, provided on August 3, 2018, at the time the wheelchair seat cushion and wheelchair back cushion were received from you. The wheelchair back and seat cushions provided August 3, 2018 serve the same purpose as the wheelchair seat cushion and wheelchair back cushion at issue. Based on the records provided, there is no indication the cushions provided met Medicare coverage criteria for replacement at the time of issue. Therefore, we decided that the Plan does not have to pay for the wheelchair cushions provided on September 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the X-ray of the chest or the emergency department visit.
You asked the Plan to waive the deductible for the X-ray of the chest and copayment for the emergency department visit. You say that you were sent home by the hospital and later tested positive for COVID-19 at a different hospital. The Plan denied your request. The Plan says you received emergency care and therefore the correct cost share was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for outpatient hospital services and a $90 copayment for emergency room visits. The X-ray of the chest you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services. You have been asked to pay $72.54, applied to your deductible, for the X-ray of the chest. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the X-ray of the chest was received on December 7, 2020.
In addition, you have been asked to pay $17.46 for the emergency department visit. An emergency department visit requires a $90 copayment amount. You have been asked to pay an amount that is less than the required copayment. Therefore, we decided that the Plan does not have to waive the deductible for the X-ray of the chest and emergency department visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis billed for date of service October 2, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the medical records provided support the item in dispute. The Plan denied your request. The Plan says the documentation provided is not sufficient to support payment of this claim.

The Plan must follow Medicare rules. Medicare rules say that when a supplier utilizes a shipping service or mail order their two options for the date of service on the claim include the date the shipping service label was created, or the date of the delivery. 

We looked at the file and Medicare rules. The records show that the claim in dispute was billed with a date of service of October 2, 2020. The proof-of-delivery document shows that the shipping service label was created on September 29, 2020, and that the delivery date of the item was October 1, 2020. This means that the date of service billed on the claim in dispute was not appropriate. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis billed for date of service October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 27216) provided on September 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Procedure code 27216 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 27216) provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional services for allergen immunotherapy not
including provision of allergenic extracts; two or more injections coded 95117 provided from May 1, 2020, to
May 22, 2020.
You asked the Plan to pay for the professional services for allergen immunotherapy not including provision of
allergenic extracts; two or more injections. 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 95117 is professional services for allergen
immunotherapy not including provision of allergenic extracts; two or more injections.
We find that CPT code 95117 is not supported in the medical record. Specifically, five units of this service
were billed. Per the Hospital OPPS conditional APC processing assignment as exceeding units for multiple
service dates present. Therefore, we find the Medicare rule of CPT code 95117 (five units) has not been met
per Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of the
professional services for allergen immunotherapy not including provision of allergenic extracts; two or more
injections have not been met. Therefore, we decided that the Plan does not have to pay for the professional
services for allergen immunotherapy not including provision of allergenic extracts; two or more injections
coded 95117 provided from May 1, 2020, to May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that review of the medical records will support the retro authorization request. The Plan denied your request. The Plan says services rendered by non-participating providers require 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 provider in this case is not a network provider with the Plan. The Plan had network providers available to provide the services at issue in this appeal. The Plan did not pre-approve the services. 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 medical services provided on September 25, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided December 22, 2019.
You asked the Plan to pay for the emergency visit. You say that the enrollee came to ED for productive cough and headache. Medical record attached for your review. The Plan denied your request. The Plan says the medical record does not support code billed per the code definition. The plan paid the level of service 99282 according to the service provided.
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 99284 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. 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 emergency visit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation submitted was reviewed, and does not meet criteria. Documentation supports CPT 99282. Exam documented supports an expanded problem focused history, exam and HPI focused on respiratory system, and EENT. Medical decision making supports moderate severity for prescription drug management. Therefore, documentation supports Evaluation and Management CPT 99282 for exam and HPI focused on the respiratory system. 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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided December 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for a surgical injection (20610) services provided on August 5, 2020, August 12, 2020 and August 19, 2020.
You asked the Plan waive the copayment for a surgical injections. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $225 copayment for each Medicare covered ambulatory surgical center visit for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $225 copayment for each Medicare covered ambulatory surgical center visit for surgical injections. This service 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 waive the copayment for a surgical injection (20610) services provided on August 5, 2020, August 12, 2020 and August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and fluoride application (D1206) provided on August 11, 2020.
You asked the Plan to pay for the dental services. You say that you were unaware that the dentist performed the treatment in February. You say that the dentist was in network so you were unaware that the Dental Plan had paid that claim. You also say that you thought that the August 2020 claim would be paid instead. The Plan denied your request. The Plan says 1 oral exam per calendar year is covered. The Plan says that 1 prophylaxis per calendar year is covered. The Plan says that the frequency limits have been exceeded. The Plan also says that fluoride application is not listed as a covered service.
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 limits for oral exams and cleanings have been exceeded. The record shows that the Dental Plan paid for these services that you received on February 25, 2020. Additionally, fluoride application is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and fluoride application (D1206) provided on August 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the Cologuard test provided on August 13, 2020.
You asked the Plan to waive the deductible for the Cologuard test. You say that you would like the claim reprocessed as in-network and for the Plan to pay your claim in full. You say the Cologuard test should have a $0 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $5,100 deductible that applies towards the Cologuard test. The Cologuard test you asked the Plan to waive the deductible for falls within the "Colorectal cancer screening" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $5,100 deductible that applies towards the Cologuard test. Until you meet your yearly deductible, you pay up to 100% of the Medicare-approved amount. This cost sharing is a contractual obligation that had not been met at the time the Cologuard test was received on August 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the Cologuard test provided on August 13, 2020.