Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from January 5, 2021 to January 28, 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 claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a RAP.
We looked at the file and Medicare rules. The file shows that the services were not billed with a required RAP
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 home health services rendered from
January 5, 2021 to January 28, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine electrocardiogram (ECG) with at least 12 leads (93000) provided February 12, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you don't think it's fair that you should be responsible for this amount since the plan always promotes yearly physical exams to it's patients as preventative medicine, and this exam was part of your yearly physical. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copayment for non-radiological diagnostic services.

You have been asked to pay $21.48 for the diagnostic service. Since the allowed amount is less than the copayment amount, you are responsible for the lesser amount. The diagnostic service 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 routine electrocardiogram (ECG) with at least 12 leads (93000) provided February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve a seat lift mechanism. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section 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 a seat lift mechanism. Our reviewer says that the documentation does not support that the requested seat lift mechanism is medically reasonable or necessary. Our physician reviewer found the enrollee does not have objective evidence of arthritis of the hip or knee or a neuromuscular disease. The documentation does not specifically reveal that the enrollee is completely incapable of standing up from a regular armchair or any chair in their home.

The seat lift is not likely to effect improvement in the enrollee's condition or arrest deterioration in the enrollee's condition. The patient does have the ability to ambulate. Therefore, the enrollee does not meet criteria for the requested item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel provided on February 17, 2021.

You asked the Plan to pay for the definitive drug testing panel. You say that the lab should not be penalized for being out of network for COVID testing. The Plan denied your request. The Plan says this claim was for drug testing, and the place of service code reported is not correct.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, the claim appealed and for which the waiver of liability was submitted was for definitive drug testing. However, the appeal letter refers to COVID testing, and the records submitted were for such testing done on January 4, 2021.

No valid records for the drug testing at issue in this claim were submitted by the provider. As such, we cannot confirm that Medicare coverage criteria were met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. You say that you are critical condition and cannot sleep at night without a ventilator. You say that a continuous passive airway pressure (CPAP) machine does not work for you. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested type of breathing machine.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a portable ventilator. Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized with acute on chronic hypercarbic respiratory failure. There is a diagnosis of chronic obstructive pulmonary disease (COPD), although this is not confirmed with pulmonary function tests. The enrollee was treated in the hospital with bilevel positive airway pressure (BiPAP) and improved. Although the clinical notes state failure of BiPAP, this is not documented in the home setting using Medicare criteria. The enrollee reportedly has continuous positive airway pressure (CPAP) at home, so there may also be a diagnosis of obstructive sleep apnea (OSA). The enrollee may benefit from BiPAP at home. But Medicare does not cover a home ventilator when used as BiPAP. Certain BiPAP devices are able to provide the average volume-assured pressure support (AVAPS) mode of support.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95886, CPT 95909, CPT 95938) provided to the enrollee on January 7, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of the denied codes is:

CPT 95886:

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs

CPT 95909:

Nerve conduction studies; 5-6 studies

CPT 95938:

Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation supports that the services were performed at a facility in a mobile unit. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for neurology services (CPT 95886, CPT 95909, CPT 95938) provided to the enrollee on January 7, 2021.
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 the clinical information provided supports the need for LTACH care. The Plan denied your request. The Plan says the enrollee can receive the care required in the current hospital.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with altered mental status and acute encephalopathy. The enrollee is awaiting feeding tube placement and undergoing weaning trials. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.

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 an additional amount for a crown (D2740), a core buildup (D2950), fillings (D2332, D2335), and endodontic therapy (D3320) provided on February 9, 20201.
You asked the Plan to pay an additional amount for a crown, a core buildup, fillings, and endodontic therapy. You say that you were not aware the annual maximum had been met. You told the provider that you only wanted procedures that would be covered under your benefit. The Plan denied your request. The Plan says the services are covered benefits, however the benefit maximum had already been met. A core buildup is not listed as a covered benefit.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown, a core buildup, fillings, and endodontic therapy have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum. Additionally, a core buildup is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for a crown (D2740), a core buildup (D2950), fillings (D2332, D2335), and endodontic therapy (D3320) provided on February 9, 20201.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided March 22, 2021.

You asked the Plan to pay for the crown. You say that you were billed for the crown and you feel it should be covered. The Plan denied your request. The Plan says you have met the benefit maximum of one crown every 60 months.

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. The Plan covers a crown once per tooth every 5 years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a crown was previously covered for the same tooth on June 4, 2020. Based on this information, we determined that the Plan's frequency limit for the crown has been exceeded. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided March 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided February 14, 2020, to February 29, 2020.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 ulcerative colitis, Crohn's disease, or inflammatory bowel disease and malnutrition. 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 inpatient services. Our reviewer says that the documentation does not support the correct coding of ulcerative colitis, Crohn's disease, or inflammatory bowel disease and malnutrition. Our physician reviewer found 5-day assessment ARD February 17, 2020, pays for February 14, 2020, to February 29, 2020. Billed PDPM Score KDGD1 x 15 days, validated PDPM Score after review of the additional documentation received, KDGE1 x 15 days. Documentation does not support the NTA CMG level. Clinical documentation does not support coding of ulcerative colitis, Crohn's disease, or inflammatory bowel disease and malnutrition. No documentation received showing a physician identified ulcerative colitis, Crohn's disease, or inflammatory bowel disease and malnutrition as diagnoses during the 60-day look. No documentation received to support ulcerative colitis, Crohn's disease, or inflammatory bowel disease and malnutrition as active diagnoses between February 14, 2020, and February 17, 2020. C.difficile Colitis does not meet the requirements for coding of an inflammatory bowel disease as it is not considered a chronic condition. 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 services provided February 14, 2020, to February 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on September 21, 2020.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says you do not have out-of-network benefits for vision services.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network vision provider. We looked at the file and the Plan's rules. The file shows that the vision services were not provide by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the post removal and retreatment of previous root canal therapy provided on February 3, 2021.

You asked the Plan to pay for the post removal. You say that you paid for the service in full out-of-pocket. The Plan denied your request. The Plan says The Plan agreed to pay for the retreatment of root canal therapy and the post removal is not a covered benefit.

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 post removal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the post removal and retreatment of previous root canal therapy provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 5, 2021.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says you are required to use the Plan's vision provider in order to receive the benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's optical provider. We looked at the file and the Plan's rules. The vision services were not provided by the Plan's optical provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the eye exam rendered on January 8, 2021.
You asked the Plan to adjust the copayment for these services. You say that this was a routine exam and should have a $15 copayment. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat disease or condition of the eye.
Review of the file shows that you received an eye exam from a provider not in the network. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered outpatient visit for services to diagnose and/or treat disease or condition of the eye benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to adjust the copayment for the eye exam rendered on January 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency visit provided from February 17, 2021, through February 18, 2021.

You asked the Plan to waive the copayment for the emergency visit. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received emergency care services from February 17, 2021, through February 18, 2021. You were asked to pay a $90 copayment for the emergency care. Your 2021 EOC states that enrollees must pay a $90 copayment for Medicare-covered emergency room visits. 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 emergency visit provided from February 17, 2021, through February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received on January 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not provided by a network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by a vision network provider. We looked at the file and the Plan's rules. The services in question were provided by a provider who is not in the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services you received on January 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (CPT code 76801) provided to the enrollee on February 2, 2021, by an out-of-network provider.
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 ultrasound (CPT code 76801) provided to the enrollee on February 2, 2021, by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lenses and frames (V2025 and V2100) purchased on
July 29, 2020.
You asked the Plan to pay for eyeglass lenses and frames. You say that these items are necessary. The Plan
denied your request. The Plan says rules for payment have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these items/services when obtained from a Network participating
provider.