Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using the requested medically necessary items with benefit. The Plan denied your request. The Plan says rules for DME have not been met.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of DME may not contact an individual by telephone regarding the furnishing of a covered item to the individual except in specific circumstances outlined in the Medicare rules section. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and a suspension sleeve have not been met. Specifically, the Plan has indicated that this enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no payment may be made for these items. Therefore, we decided that the Plan does not have to pay for a left knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on July 14, 2020.

You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The service at issue was reported with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on July 29, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the claim was billed with a laboratory place
of service code but the specimen was collected in an office setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting
where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Specifically, the claim was billed with a laboratory
place of service code but the documentation submitted suggests that the member's face-to-face services were
rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing
services (G0482) provided on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces (L1833, L2397) provided on October 5, 2020.

You asked the Plan to pay for knee braces. You say that this should be covered due to Covid-19 guidelines. The Plan denied your request. The Plan says this was provided following an unsolicited phone call.

The Plan must follow Medicare rules. Medicare rules say that with limited exceptions, a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual.

We looked at the file and Medicare rules. The Plan attests that the enrollee received an unsolicited phone call regarding the items at issue. Based on this information, we decided that Medicare rules for coverage of knee braces have not been met. Therefore, we decided that the Plan does not have to pay for knee braces (L1833, L2397) provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on January 19, 2021.
You asked the Plan to pay for the home visit. You say that the patient is in a facility and the hospitalist is the only provider the patient has. You say that the claim should be reviewed and processed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 home visit provided by an out-of-network provider on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance and four gingival irrigations provided on November 3, 2020.
You asked the Plan to pay for the periodontal maintenance and gingival irrigations. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.
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 the periodontal maintenance and four gingival irrigations provided on November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 12, 2020.
You asked the Plan to pay for the dental service. You say that there was no frequency at all for this service. You say that you had last seen your dentist in January for a cleaning and exam. You say that the exam on October 12 was for a specific problem. You say that that provider was not able to solve your problem and sent you to an endodontist. You also say that your appointment with the endodontist was covered. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also says that the frequency limit has been exceeded.
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 and limited oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the limited oral evaluation that you received on October 22, 2020. Additionally, the claim for date of service October 22, 2020, was received before the claim date of service October 12, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient post-stabilization services provided to the enrollee from October 10, 2020 to October 12, 2020.

You asked the Plan to pay for the services. You say that the services provided were medically reasonable and necessary both for the treatment of the enrollee's condition and on an inpatient hospital basis per the treating physician.The Plan denied your request. The Plan says the provider failed to request authorization to provide post-stabilization care once the enrollee's emergency condition had stabilized.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the review indicates that all inpatient care provided after 10:01 am on 10/11/20 through 7:00 pm on 10/12/20 was not needed on an emergent basis. The enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport to a plan-approved ICU for continued inpatient level of care services. There was no documentation provided necessitating post-stabilization care services after 10:01am from October 10, 2020 to October 12, 2020 at the non-plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.

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 services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient post-stabilization services provided to the enrollee from October 10, 2020 to October 12, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/tub stool (E0245).

You asked the Plan to pre-approve a bath/tub stool (E0245). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a bath/tub stool is not covered by Medicare or the Plan.

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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a bath/tub stool (E0245).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on October 16, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you should be covered fully.The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,856.48. The total amount you are being asked to pay is $371.30 ($1,856.48 x 20% = $371.30). An injection falls within the Medicare Part B prescription drugs 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 coinsurance for an injection provided by a participating provider on October 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 11, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 CPT code G0482 is not supported in the medical record. Specifically, 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 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 for the drug testing coded G0482 provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan must hold you harmless for the determination of refractive state (92015).
You asked the Plan to pay for the determination of refractive state. You say that you were offered a vision exam for glasses and refused it. The Plan denied your request. The Plan says that vision services are only covered when received from a network provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan denied coverage for this eye refraction as this service is only covered as part of a routine exam, and you underwent a medical eye exam. However, you state that you were offered this $45 noncovered vision check during this visit, but you state that you refused it, because you did not want to obtain glasses from this provider. The Plan has not properly investigated this issue. No attempts to obtain medical records are documented. Without some evidence to refute your statement that you refused this eye refraction, such as documentation that the test took place, we cannot confirm whether you are responsible for this amount. As such, we find that the plan's denial is not substantiated. Therefore, we decided that the Plan must hold you harmless for the determination of refractive state (92015).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 16, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says at the present time, medical care is ongoing, and the amount of therapy is appropriate to meet needs.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Adakveo.

You asked the Plan to pre-approve Adakveo. You say that the requested Adakveo is medically necessary. The Plan denied your request. The Plan says that the requested Adakveo is not medically necessary.

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 Adakveo. Our reviewer says that the requested Adakveo is medically necessary. Our physician reviewer found the rules indicate that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable and necessary. Adakveo is indicated to reduce the frequency of vaso-occlusive crises (VOCs) in adults and pediatric patients aged 16 years and older with sickle cell disease.

In this case the enrollee experiences vaso-occlusive crisis from sickle cell anemia. The elements of the coverage rules are satisfied. The requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Adakveo have been met. Therefore, we decided that the Plan has to pre-approve Adakveo.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit provided November 18, 2018 to November 29, 2018.
You asked the Plan to waive the copayment for the emergency services. You say that additional information was requested which was never received to issue payment on this claim. You were not aware of this until approximately 15 months after date of service. The Plan denied your request. The Plan says the claim has processed and the correct copayment has been 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 $80 copay for each emergency room visit. You have been asked to pay $80 copay for the emergency services. The emergency services fall within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit provided November 18, 2018 to November 29, 2018.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COVID-19. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision services provided on August 25, 2020, September 8, 2020, and December 1, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you had a detached retina and needed surgery. You say that the tests were required, and you should not be billed. The Plan denied your request. The Plan says the claim reprocessed to apply a $25 copayment for each date of service.
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 $25 copayment for additional diabetic eye exams and all other Medicare-covered eye exams. Covered services include outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. You have been asked to pay a total of $75 for the vision services. ($25/visit x 3 visits = $75). The vision services fall within the "Vision Care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the vision services provided on August 25, 2020, September 8, 2020, and December 1, 2020.