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

We decided that the Plan does not have to pay for the closed treatment of fracture services coded 28510 provided on September 29, 2020.
You asked the Plan to pay for the closed treatment of fracture services. 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 28510 is closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each. We find that CPT code 28510 is not supported in the medical record. Specifically, the submitted medical records do not contain sufficient detail to support the billed charges. The documentation does not detail what method of closed treatment was performed. Based on this information, we decided that Medicare rules for coverage of the closed treatment of fracture services have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of fracture services coded 28510 provided on September 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 8, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you had ultrasounds in the past and did not pay a copayment. You say that the appointment was set up for preventive measures and the copayment should be waived. 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 $100 per day for a Medicare-covered ultrasound. You have been asked to pay $93.54, which is less than the standard $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a diagnostic service. 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 ultrasound provided on January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation feature.
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the seat elevator does not serve a primary medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a seat elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the request cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the stimulator. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found coverage for this device is limited to spinal cord injury patients. The diagnosis in this case is multiple sclerosis and right foot drop, not a spinal cord injury. There is also no history of at least a six-month post recovery spinal cord injury and restorative surgery. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 31, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 2, 2020, by an
OON provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
You say that these services were medically necessary. The Plan denied your request. The Plan says prior
authorization was not obtained by the member's primary care physician. The Plan says that there are in-network
providers available 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 physician services provided on December 2, 2020,
by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility discharge services provided on
January 31, 2020.
You asked the Plan to pay for the nursing facility discharge services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for nursing facility discharge services provided on
January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a deep brain stimulator.
You asked the Plan to pre-approve a deep brain stimulator. You say that this service is medically necessary.
The Plan denied your request. The Plan says that the enrollee is enrolled in hospice care and thus not eligible to
receive payment for these services under their Medicare Advantage plan.
The Plan follows Medicare rules. Medicare rules say that Original Medicare, not the Plan, is responsible for all
Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The
rules say that the Plan may direct the provider to bill Medicare directly for these services. Medicare rules also
say that coverage of the DBS is subject to the criteria listed in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a deep brain stimulator. Our reviewer
says that the requested item is medically reasonable and necessary. Our physician reviewer found that in this
case the member previously underwent DBS placement. The applicable NCD does not readily discuss followup
care of the DBS device (rather it focuses on initial eligibility). As the member has already undergone DBS
placement and they are no long in hospice, it can be said to be reasonable and necessary for them to continue to
receive maintenance/adjustments on their DBS unit. Such services would otherwise be readily consistent with
standards of care/practice.
We looked at this physician's review, the file, and Medicare rules. In this case, the enrollee is no longer
receiving hospice benefits. Based on this information combined with this physician's review, we decided that
Medicare rules for coverage of a deep brain stimulator have been met. Therefore, we decided that the Plan has
to pre-approve a deep brain stimulator.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the total knee arthroplasty surgery (27447) provided on November 24, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance per Medicare-covered visit for outpatient surgery. You have been asked to pay $2,344.58 (Plan allowed amount of $11,722.91 x 20% coinsurance) for the outpatient surgery provided. 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 coinsurance for the total knee arthroplasty surgery (27447) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device (E0676) provided
on September 17, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial
for payment. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's
contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a Pneumatic Compression Device (PCD) that
provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a
preventive service. Items that are used for a preventative service or function are excluded from coverage under
the Medicare DME benefit.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this item have not been met. Specifically, a Pneumatic Compression Device that provides
intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive
service that is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the
intermittent limb compression device (E0676) provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on May 4, 2020 and May 5, 2020.
You asked the Plan to pay for the laboratory services. You say that medically necessary services were provided in good faith and you are seeking consideration for the services rendered. The Plan denied your request. The Plan says network providers were available to perform the 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 laboratory services provided by an out-of-network provider on May 4, 2020 and May 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided December 31, 2020 to January 2, 2021.
You asked the Plan to pay for the inpatient services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says expenses incurred in different calendar years cannot be processed as a single claim. A separate claim is required for the expenses incurred in each calendar year
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the claim was billed incorrectly. A separate claim is required for the expenses incurred in each calendar year. The provider needs to submit corrected claims for December 31, 2020 and then January 2021 and include the modifier that indicates it was one event but with the years change over. Expenses incurred in different calendar years cannot be processed as a single claim. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided December 31, 2020 to January 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 13, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 12, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 13, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided by a participating provider on January 9, 2020.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says that prior authorization was not obtained by the member's primary care physician.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for genetic testing by a contract provider. These services were referred by the member's primary care physician. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided by a participating provider on January 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 30, 2019.

You asked the Plan to pay for the lab services. You say that your records indicate the claim was filed timely. The Plan denied your request. The Plan says the claim was received past the allowed time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the lab services was not filed until June 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
November 17, 2020, through November 25, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial of payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $395
copayment per day for days 1 through 5 for Medicare-covered hospital stays at an in-network hospital.
Additionally, there is no coinsurance, copayment, or deductible for days 6 through 90.
You have been asked to pay $1975 ($395 copayment x 5 days) for the inpatient hospital care provided. 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 care provided from November 17,
2020, through November 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from January 7, 2021, to January 28, 2021.
You asked the Plan to waive the copayments for outpatient mental health care. You say that you feel that the enrollee should not be responsible for copayments in 2021. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
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 $25 copayment for outpatient mental health care. The enrollee received outpatient mental health care from January 7, 2021, to January 28, 2021, for a total of 4 visits. Therefore, the enrollee is being charged a $25 copayment per each visit. The total amount the enrollee owes is: $25 (copayment) x 4 (outpatient mental health visits) = $100. The enrollee has been asked to pay the total copayment amount of $100 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient mental health care provided from January 7, 2021, to January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Group 2 power wheelchair (K0842) with multiple accessories provided on September 28, 2020.
You asked the Plan to pay for a Group 2 power wheelchair with multiple accessories. You say that the requested item will be upgraded for free to a Group 3 chair. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that a SWO must be communicated to the supplier prior to claim submission.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Group 2 power wheelchair with multiple accessories have not been met. Specifically, the record shows that the order did not match the item billed. A Group 3 power wheelchair was ordered, and a Group 2 power wheelchair was billed for. Therefore, we decided that the Plan does not have to pay for a Group 2 power wheelchair (K0842) with multiple accessories provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 22, 2020.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on December 22, 2020.