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

We decided that the Plan does not have to pay for the surgical services rendered on February 10, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that codes with a PC/TC indicator of 5 are not payable to the hospital outpatient or inpatient place of service. We looked at the file and Medicare rules. The file shows that procedure code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) has a PC/TC indicator of 5 and was billed with place of service code 23 for an emergency room.
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings identified with code A6530 purchased
on February 24, 2021.
You asked the Plan to pay for the compression stockings. You say that compression stockings are medically
necessary, and they were covered before. The Plan denied your request. The Plan says the specific compression
stockings purchased are coded as A6530 which are not covered by Medicare. The Plan recommends that you
speak to your physician regarding what compression stockings would be covered.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530
not covered by Medicare. Compression stockings are only covered under certain circumstances. The
compression stockings purchased are not covered by Medicare. Therefore, we decided that the Plan does not
have to pay for compression stockings coded as A6530 purchased on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's illness is not complex enough to require daily physician management and the enrollee does not require specialized nursing services that are only available in an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to be stable and improving. Only short term additional acute care services are required which can safely be received at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for acupuncture provided on April 13, 2021.
You asked the Plan to waive the copayment for acupuncture. You say that the Plan normally fully reimburses you. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $15 copayment for acupuncture for chronic low back pain. You have been asked to pay a $15 copayment for acupuncture. Acupuncture falls within the acupuncture for chronic low back pain 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 acupuncture provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 20, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on August 3, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99239.

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 99239 is hospital discharge day management; more than 30 minutes. 

We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of hospital discharge services of more than 30 minutes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on March 16, 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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on March 3, 2021.
You asked the Plan to pay for this claim. You say that this device was used during the enrollee's surgery and should be covered by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility.
Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee on March 3, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that the requested Evenity is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Prolia or Reclast first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
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 Evenity. Our reviewer says that the
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Prolia
and Reclast first before they will approve the requested drug. In this case, the enrollee has not tried and failed
the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely
be less effective and/or likely have adverse effects 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 Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for an emergency department visit (99284) and an intravenous infusion (IV) into a vein for hydration (96361) provided on March 27, 2021, to March 28, 2021.
You asked the Plan to waive the cost-shares for an emergency department visit and an IV. You say that the claim was not filed correctly since you were not admitted to the hospital. The Plan denied your request. The Plan says the cost-shares you are being charged are correct.
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 $90 copayment for emergency care. Your contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $90 copayment for an emergency department visit and a 20% coinsurance for an IV. The EOC confirms that $90 is the required copayment for an emergency department visit. The EOC also confirms that 20% is the required coinsurance for an IV into the vein for hydration. The allowed amount of the claim for the IV is $255.22, resulting in a coinsurance obligation of $51.04. Your total cost-share amount is $141.04 ($90 + $51.04 = $141.04). 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 cost-shares for an emergency department visit (99284) and an intravenous infusion (IV) into a vein for hydration (96361) provided on March 27, 2021, to March 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote evaluation of your defibrillator
that you received on February 17, 2021.
You asked the Plan to waive the copayment for the remote evaluation of your defibrillator. You say that you
have never had a copayment for this service in the past. The Plan denied your request. The Plan says you were
charged this copayment 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 $40
copayment for diagnostic tests.
You have been asked to pay a $40 copayment for the remote evaluation of your defibrillator. The remote
evaluation of your defibrillator falls within the diagnostic tests 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 remote evaluation of your defibrillator that you received
on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift/stairway elevator for the enrollee.
You asked the Plan to pre-approve the lift. You say that coverage is needed due to the cost of the equipment. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift/stairway elevator for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy and does not have to waive the coinsurance for a Medicare Part B drug injection provided on May 11, 2021.
You asked the Plan to waive the copayment for a diagnostic colonoscopy and to waive the coinsurance for a Medicare Part B drug injection. You say that you had to receive multiple colonoscopies and you called the provider for an explanation of a bill you received and were just told you have to pay. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $0 copayment for diagnostic colonoscopies provided on the same date of service as the corresponding preventative test and a $50 copayment for all other tests. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a diagnostic colonoscopy on May 11, 2021. The record shows that your colonoscopy screening was received on a previous date. Therefore, you are responsible to pay the $50 copayment. You received a Medicare Part B drug on May 11, 2021. The total allowed amount is $283.10 and 20% of that is $56.62. The total amount you owe is $106.62. You have been asked to pay the total amount of $106.62 for a diagnostic colonoscopy and a Medicare Part B drug injection. A diagnostic colonoscopy falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug 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 copayment for a diagnostic colonoscopy and does not have to waive the coinsurance for a Medicare Part B drug injection provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomographic (CT) angiography (75635) provided on February 10, 2021.

You asked the Plan to pay for a CT angiography. You say that this was billed with an appropriate diagnosis. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.

The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.

For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. The services at issue were billed with a primary diagnosis of I70.92, chronic total occlusion of artery of the extremities. This is a manifestation code, meaning the underlying condition should be coded first and this is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for coverage of a CT angiography have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomographic (CT) angiography (75635) provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 29, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you believe these services were denied due to a coding error. 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 problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from April 23, 2019, through April 25, 2019.
You asked the Plan to pay for the inpatient hospital care. The Plan denied your request. The Plan says a corrected claim must be receive within one year (12 months) from the processed date of the original claim submission.
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 inpatient hospital care was not filed until April 27, 2021. 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 inpatient hospital care provided from April 23, 2019, through April 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1852).
You asked the Plan to pre-approve the orthosis. You say that you have provided clinical documentation along with the physician order to assist with the review of this request. The Plan denied your request. The Plan says the records do not support that the enrollee meets the medically necessary criteria for approval.
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has arthritis of the knee. The record does not indicate that the enrollee had a recent injury or procedure on the knee. The provided record does not document instability based upon objective evidence of joint laxity. The elements of the coverage rule are not satisfied. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1852).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.
You asked the Plan to pre-approve SNF services. You say that the facility is refusing to release the member from the SNF saying they are not fit or safe enough to go home. You say that the authorization should be approved since the facility is saying the member needs further care. The Plan denied your request. The Plan says the request is not medically necessary.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee was medically stable and has no daily skilled nursing needs. Our reviewer says that since skilled therapy was not required on a daily basis in an inpatient setting, continuation beyond the date approved is not medically reasonable and necessary. Our reviewer also says that rehabilitation need could be met 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (22846) provided to the enrollee from December 8, 2020 to December 11, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not coded correctly.
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 22846 is "Insertion of anterior spinal instrumentation for spinal stabilization, 4 to 7 vertebral segments." We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in this case, the record does not contain clinical records to determine what procedures were performed. As such, whether the requested service is appropriately billed cannot be determined.
We looked at the 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 hospital services (22846) provided to the enrollee from December 8, 2020 to December 11, 2020.