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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 20, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483You asked the Plan to pay forthe drug testing. 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 supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation did not contain sufficient detail to support the billed charges. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an outpatient rehabilitation setting place of service 57. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0483
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 22, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the plan and authorizationwas not 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 forthe medical services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Envarsus.You asked the Plan to pre-approve Envarsus. You say that the enrollee is stable on chronic immunosuppressant therapy.The Plan denied your request. The Plan says the requested drug is not covered under the enrollee's Part B plan.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 pre-approve Envarsus.Benefits for Envarsus may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 97163 provided on September 17, 2019.You asked the Plan to pay forCPT code 97163. 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. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97163 is Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.We find that CPT code 97163 is notsupported in the medical record. Specifically, the documentation submitted for CPT code 97163 is signed by a physical therapy assistant (PTA). CPT code 97163 is to be performed by a physician or other qualified health professional. Per CMS, PTA's are not permitted to perform evaluations, assessment procedures, or certain complex procedures; nor do they design plans of care or develop treatment plans. Accordingly, PTAs do not possess an independent "scope of practice" as do physical therapists. Based on this information, we decided that Medicare rules for coverage of CPT code 97163 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 97163 provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you fora transfer bench and a standard wheelchair purchased on October 2, 2019.You asked the Plan to reimburse you fora transfer bench or standard wheelchair. You say that you saved the Plan money by buying these items from the closest place to obtain them from.The Plan denied your request. The Plan says transfer benches arenot a covered benefitand wheelchairs must be rented.The Plan must follow Medicare rules. Medicare rules say that transfer benches are not covered because they are not primarily medical in nature. Medicare rules say that a manual wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual wheelchair.While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Only rented wheelchairs are covered. Therefore, we decided that the Plan does not have to reimburse you fora transfer bench and a standard wheelchair purchased on October 2, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in
the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care
and services. The only exceptions are emergencies, urgently needed care when the network is not available
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan
authorizes the use of out-of-network providers. You can find this information on page 33 of the Plan's 2019
Evidence of Coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe wound care services. You say that you would like reconsideration because these services were medically necessary.The Plan denied your request. The Plan says this routine care was provided by a non-Plan provider and not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care fromout-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 forthe medical services provided on January 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe chemodenervation provided on November 19, 2019.You asked the Plan to waive the copayment forthe chemodenervation. You say that you have never paid this type ofcopayment before. You say that the coding is incorrect.The Plan denied your request. The Plan says the copayment 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $230.09, which is less than the standard $295 copayment for the chemodenervation. The chemodenervation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The chemodenervation is considered a surgical procedure that was provided by the hospital. 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 forthe chemodenervation provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.You asked the Plan to pay for foot orthotics. You say that your treating physician ordered the orthotics to prevent further deterioration of your foot. You say that previously you had received notice of the Plan's acceptance of the orthotics and that it is ridiculous that the Plan is now declining payment for them. You stated that without the orthotics there would probably have been a reoccurrence of your foot issues and you would have had to visit your physician for corrective procedures.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on February 13, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you had authorization. You say that you paid your $35 copayment. The Plan denied your request. The Plan says the copayment 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 $200 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $200 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure. 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 arthrocentesis provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are available from network providers.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 availablewho 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-approvea referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) provided on January 11, 2020. You also asked the Plan to pay the new rate for the crown (D2740) provided on January 13, 2020. You asked the Plan to pay for the therapeutic pulpotomy. You say that your new dental coverage was effective on February 1, 2020. You say that the dentist submitted your claim too early. You also say that you have a hole in your upper right jaw that hurts as well as pain in your lower left jaw. The Plan denied your request. The Plan says the therapeutic pulpotomy is not a covered service. The Plan also says that additional payment cannot be made on the services you received in January as they have already been paid according to the dental coverage that you had at the time you received 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 pulpotomy is not among those covered under this benefit. Additionally, the requested additional payment for the crown under your new dental coverage cannot be made. The record shows that the crown was already paid for under the dental coverage that was active at the time you received the service. Therefore, we decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) provided on January 11, 2020. The Plan also does not have to pay the new rate for the crown (D2740) provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection, 5 units, that you received during an outpatient hospital stay on January 15, 2020.
You asked the Plan to pay for the insulin injection. You say that your hospital stay should be fully covered. The Plan denied your request. The Plan says the insulin injection is considered a "self-administered" drug. The Plan says self-administered drugs are not covered under your Medicare Part B coverage.
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 the insulin injection, 5 units, that you received during an outpatient hospital stay on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, first intraoral periapical x-ray, additional intraoral periapical x-ray, adjunctive pre-diagnostic test, two gingival irrigations, scaling in presence of generalized moderate or severe gingival inflammation, and topical application of fluoride varnish provided on December 9, 2019 and December 16, 2019.
You asked the Plan to pay for the dental services. You say that this provider is in-network with your plan. You also say that you have a quarterly allowance of $425 and these procedures were for needed dental work. The Plan denied your request. The Plan says the maximum allowed amount for your quarterly maximum of the 4th quarter had been met.
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, $425.00 allowance for comprehensive dental services every quarter. Any amount not used at the end of a quarter will carry over to the next quarter, which totals $1,700 per year. The record shows that you met the annual maximum benefit on November 1, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings, first intraoral periapical x-ray, additional intraoral periapical x-ray, adjunctive pre-diagnostic test, two gingival irrigations, scaling in presence of generalized moderate or severe gingival inflammation, and topical application of fluoride varnish provided on December 9, 2019 and December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from February 19, 2019 to February 20, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that this should be paid because the enrollee left against medical advice.The Plan denied your request. The Plan says inpatient care was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department on February 19, 2019 and reported having the chest pain every morning since she had her blood thinner medication changed two weeks prior, as well as shortness of breath at night and a constant dry cough. Otherwise, there were no other symptoms or recent travel.  Her vitals were normal and stable. There were no acute findings on a chest x-ray. The enrollee was evaluated and admitted but left against medical advice on February20, 2019. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from February 19, 2019 to February 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you called 911 and the responding medics checked and evaluated you. You say that they determined your heart was okay but you needed to go to the hospital. You stated that they told you that you could either drive to the hospital or they could transport you by ambulance. Your husband suggested that you drive yourself in order to save the Plan the cost of the ambulance. You say that the claim was denied because of a technicality and that this was a legitimate health care charge. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.