Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.

You asked the Plan to pre-approve 10 additional occupational therapy visits. You say that you are making progress, but you need to continue therapy. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 10 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy and your functional level does not require ongoing skilled therapy services. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99223) provided November 19, 2020 to November 22, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 99223 is comprehensive history, comprehensive examination, medical decision making of high complexity. 

We find that CPT code 99223 is not supported in the medical record. Specifically, the provided records do not support that the services were of high complexity. CPT 99222 would be more appropriate for this service.

Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99223) provided November 19, 2020 to November 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the Signia 3x device hearing aid and does not have to pay for the Signia Cross X device hearing aid provided on February 10, 2021.

You asked the Plan to pay an additional amount for the Signia 3x device hearing aid and to pay for the Signia Cross X device hearing aid. You say that you understood that you would be reimbursed for some of these costs according to the Plan. You say that you get information all the time stating that the hearing aids are reimbursable. The Plan denied your request. The Plan says the correct cost share was applied to the claim for the Signia 3X and the Cross X is not a covered device listed on the Plan hearing aid benefit formulary.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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 correct cost share was applied to the clam for the Signia 3X device and the Cross X device is not a covered device listed on the Plan hearing aid benefit formulary.

Therefore, we decided that the Plan does not have to pay an additional amount for the Signia 3x device hearing aid and does not have to pay for the Signia Cross X device hearing aid provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 20, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day, for the evaluation and management of a patient (99223) for December 18, 2020, and hospital discharge day management (99239) for December 21, 2020.

You asked the Plan to pay for the initial hospital care and hospital discharge day management. You say that the services were medically necessary. The Plan denied your request. The Plan says 99223 and 99239 are not supported for the dates in question

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 99223 - inpatient services provided with initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit and 99239 - hospital discharge day management; more than 30 minutes. We asked our coder 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 initial hospital care and hospital discharge day management. Our reviewer says that the services provided on December 18, 2020, and December 21, 2020, do not meet criteria for billing or reimbursement consideration. Our coder reviewer found that the claim for the services provided on December 18, 2020, and December 21, 2020 processed correctly. The billed codes 99223 (A comprehensive history, comprehensive examination, medical decision making of high complexity) and 99239 (Hospital discharge day management; more than 30 minutes) is not supported by the medical documentation submitted. Medical records are still needed to support CPT codes 99223 and 99239, for the requested dates of service. The reviewer has determined that the medical record does not support the billing of 99223 for December 18, 2020. The medical record does not support the billing of 99239 for December 21, 2020.

We looked at this coder'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 initial hospital care, per day, for the evaluation and management of a patient (99223) for December 18, 2020, and hospital discharge day management (99239) for December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a thoracic-lumbar-sacral orthosis (L0457) provided to the enrollee on April 13, 2021.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a thoracic-lumbar-sacral orthosis (L0457) provided to the enrollee on April 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or rehabilitation services at this time.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve SNF services. Our physician reviewer found that the enrollee is walking 30 feet with a 2-wheeled walker with contact guard assistance and is at a contact guard assist levels for transfers and activities of daily living. She is medically stable for transfer. The enrollee does not require skilled nursing or therapy services on a daily basis in an inpatient 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on May 3, 2021.

You asked the Plan to pay for a periodic oral evaluation, and a teeth cleaning. You say that these services should be covered. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum had already been met before this date.

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 periodic oral evaluation, and a teeth cleaning have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum prior to this date of service on March 4, 2021.

Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that the injection is medically necessary. The Plan denied your request. The Plan says the criteria has not completed 3 months of failed conservative management including specific modalities prior to considering hyaluronic acid injections.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

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 Euflexxa. Our reviewer says that the requested drug, Euflexxa, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has undergone any course of physical therapy. The reviewer found that the enrollee has not failed at least 3 months of conservative therapy. The reviewer also found that there is no documentation of the enrollee's response to the steroid injection. The reviewre has determined that the documentation does not support that the Euflexxa is medically reasonable or necessary for the enrollee. The reviewer also found that the documentation does not support that the Euflexxa is safe and effective for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the file shows that the enrollee has not had any physical therapy or response to a steroid injection. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on April 2, 2021.

You asked the Plan to pay for the self-administered drugs. You say that the medications were given to begin
fighting an infection on your hand, these are not medications you take on a regular basis. You say that the
infection might have been worse if there was a delay in the medications and you are appealing the charges. The
Plan denied your request. The Plan says Part B doesn't pay for self-administered drugs used in the hospital
outpatient setting.

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 self-administered drugs provided on April 2, 2021.

Benefits for the self-administered drugs 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 10, 2021, through April 13, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you want the Plan to pay for the charges. 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). Your contract with the Plan clearly says that you must pay a $343 copayment per day, for days 1 to 4 for inpatient hospital care. 

You have been asked to pay a $1029 copayment for inpatient hospital care. The services at issue fall 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 inpatient hospital care provided from April 10, 2021, through April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 6, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second medial branch block (MBB) (64493, 64494).

You asked the Plan to pre-approve a second medial branch block. You say that you cannot know if radiofrequency ablation is indicated without a second medial branch block. The Plan denied your request. The Plan says the first medial branch block did not provide adequate relief.

The Plan follows Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint procedure, such as a medial branch block, is considered medically reasonable and necessary only if the first diagnostic facet joint procedure provided a consistent positive response of at least 80% relief of the primary pain.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a second medial branch block have not been met. The record shows that the first procedure provided only 60% pain relief. Therefore, we decided that the Plan does not have to pre-approve a second.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), a crown (D2740), a core buildup (D2750), an intraoral periapical radiographic image (D0220), and a bitewing radiographic image (D0270) provided on April 20, 2021.

You asked the Plan to pay an additional amount for a limited oral evaluation, a crown, a core buildup, an intraoral periapical radiographic image, and a bitewing radiographic image. You say that the services should be covered. The Plan denied your request. The Plan says the provider was paid at the Medicare allowed rate for the bitewing radiographic image therefore no additional payment can be made. A limited oral evaluation, a crown, a core buildup, and an intraoral periapical radiographic image are not covered benefits.

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 requested items or services are not among those covered under this benefit. Additionally, the allowed amount of the bitewing radiographic image for an out-of-network provider was paid by the plan. Therefore, we decided that the Plan does not have to pay an additional amount for a limited oral evaluation (D0140), a crown (D2740), a core buildup (D2750), an intraoral periapical radiographic image (D0220), and a bitewing radiographic image (D0270) provided on April 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued SNF services. You say that you are being discharged too soon. The Plan denied your request. The Plan says you do not meet the requirements for approval of continued SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, you no longer qualify for SNF coverage. You do not have documented skilled nursing needs, having completed your intravenous antibiotics. You do not have documented skilled therapy needs, having reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial and, as a practical matter, can be provided at a lower 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 continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on April 2, 2021, to May 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you needed these services done. You say that this is a financial hardship for you. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 psychotherapy services provided on April 2, 2021, to May 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services (99442-GQ-GT) provided March 24, 2020.

You asked the Plan to pay for the telehealth services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says asynchronous telecommunications is not covered because it is not considered an interactive communication method.

The Plan must follow Medicare rules. Medicare rules say that telehealth services billed with a GQ modifier can only be billed when the provider is in Alaska or Hawaii. 

We looked at the file and Medicare rules. In this case, the provider is not located in Alaska or Hawaii while billing the services provided with a GQ modifier. Based on this information, we decided that Medicare rules for coverage of the telehealth services have not been met. Therefore, we decided that the Plan does not have to pay for the telehealth services (99442-GQ-GT) provided March 24, 2020.