Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the two-day inpatient hospital stay.

You asked the Plan to waive the copayment for the inpatient hospital visit. You say that this hospital stay followed a visit to the emergency room, and you were under the impression that the hospital stay would be covered under the copayment for emergency care. You say that you do not understand this $650 charge. The Plan denied your request. The Plan says there is a $325 copayment for each of the first six days of an inpatient hospital stay.

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 $325 copayment for each of the first six days of an inpatient hospital stay.

You have been asked to pay a $325 copayment for each of the two days of your inpatient stay ($325 x 2 = $650). You say that you thought the stay would be covered under the emergency care copayment because you were admitted to the hospital following a visit to the emergency room. However, the Plan contract states that you do not pay the copayment for emergency care if you are admitted to the hospital for the same condition within 24 hours. The copay costs for inpatient care still apply. 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 two-day inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 6 and 8.

You asked the Plan to pay for the dental services. You say that the services should be covered. You say that a few fillings are definitely covered. You say that you told your dentist that you only ever wanted services that would be covered, otherwise you would not pay for them. You also say that you have "special help" coverage as well. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan says that the annual maximum 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, the annual maximum benefit of $1,000 has been exceeded. The record shows that the Plan paid $491 for dental services that you received and $509 for dental services that you received. The Evidence of Coverage clearly states that you are responsible for any cost above the $1,000. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 6 and 8.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152.

You asked the Plan to pay for the moderate sedation 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 99152 is moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial fifteen minutes of intraservice time, patient
age five years or older.

We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted
did not include a moderate sedation note indicating the presence of an independent trained observer to assist in
the monitoring of the enrollee's level of consciousness and physiological status. Based on this information, we
decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we
decided that the Plan does not have to pay for the moderate sedation services coded 99152.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Computed Tomography (CT) scan.

You asked the Plan to waive the copayment for the CT scan. You say that you should not be expected to pay the copayment for advanced imaging services because you thought you were only receiving an x-ray. The Plan denied your request. The Plan says a CT scan was provided, and advanced imaging services have a $225 copay.

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 $225 copayment for advanced imaging services.

You have been asked to pay a $129.22 copayment for the CT scan. A CT scan falls within the advanced imaging services 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 Computed Tomography (CT) scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for knee arthroscopy procedures (29876 and 29879).

You asked the Plan to pay for knee arthroscopy procedures. You say that these services were medically necessary. The Plan denied your request. The Plan says these codes are not supported in the records.

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 29876 is arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral), and 29879 arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture. 

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 knee arthroscopy procedures. Our reviewer says that these codes are not supported. Our physician reviewer found CPT 29876 is not reported separately with CPT 29880. A synovectomy to clean up a joint on which another more extensive procedure is performed is not separately reportable. CPT 29879 was not clearly documented. The documentation supports debridement/shaving of articular cartilage, not abrasion arthroplasty or multiple drilling or microfracture. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroscopy procedures have not been met. Therefore, we decided that the Plan does not have to pay for knee arthroscopy procedures (29876 and 29879).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the behavioral health services. You say that you would like reconsideration because it was not your decision to have these services. The Plan denied your request. The Plan says this provider is out-of-network.

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. Additionally, the record indicates that you signed a private pay financial agreement for the services rendered. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Aspiration and/or injection of large joint or joint capsule (20610).

You asked the Plan to waive the copayment for the Aspiration and/or injection of large joint or joint capsule. You say that the cost-share is too high. The Plan denied your request. The Plan says the cost-sharing 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 $295 copayment for all other Outpatient Services including observation and outpatient surgical services not provided in an Ambulatory Surgical Center.

You have been asked to pay a $285.19 for the Aspiration and/or injection of large joint or joint capsule. This service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 Aspiration and/or injection of large joint or joint capsule (20610).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97110, 97140).

You asked the Plan to waive the copayment for physical therapy. You say that you disagree with the
copayment due to having to do physical therapy before the magnetic resonance imaging (MRI). The Plan
denied your request. The Plan says the correct copayment was 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 $35
copayment for outpatient rehabilitation services.

You have been asked to pay a $35 copayment for physical therapy. The services at issue fall within the
outpatient rehabilitation services 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
physical therapy services (97110, 97140).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (01996).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 01996 is "Daily hospital management of epidural or subarachnoid continuous drug administration".

We asked our coding 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 use of CPT code 01996 is not supported by the records provided. Our coding reviewer found that the documentation did not include "management of epidural or subarachnoid continuous drug administration." The documentation included operative note, preoperative documentation and nursing notes. Therefore, this service cannot be verified.

We looked at this coder'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 the services (01996).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an angiogram and angioplasty of the legs.

You asked the Plan to pre-approve an angiogram and angioplasty of the legs.. You say that the requested services are medically necessary due to the enrollee's severity of pain and discoloration. The Plan denied your request. The Plan says the enrollee does not have clinically significant occlusive vascular disease.

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 an angiogram and angioplasty of the legs. Our reviewer says that an angiogram and angioplasty of the legs are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support the medical necessity of the procedure in question. The documentation suffers from a lack of clarity with respect to the enrollee's vascular status. The enrollee's physical examination findings are inconsistent with the impression and there is no pulse examination and no noninvasive vascular imaging studies. The only objective information is an angiogram performed approximately 1 month after his cardiac catheterization, approximately 5 months ago, that demonstrated isolated common iliac artery stenosis of 30% on the right and 40% on the left. Is not possible to overturn the health plan's determination on the basis of medical necessity without a more cogent evaluation and assessment, pulse examination, and noninvasive studies that support repeat angiography.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an angiogram and angioplasty of the legs. have not been met. Therefore, we decided that the Plan does not have to pre-approve an angiogram and angioplasty of the legs.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care services coded S9124.

You asked the Plan to pay for the nursing care 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 payable.

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 S9124 is nursing care, in the home, by licensed practical
nurse, per hour.

We find that CPT code S9124 is not supported in the medical record. Specifically, this code has a status code
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the nursing care services have not been met. Therefore, we decided that the Plan does not have to
pay for the nursing care services coded S9124.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision-correcting intraocular lens (IOL).

You asked the Plan to pay for the vision-correcting IOL. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.

The IOL you asked the Plan to pay for is not a covered benefit under Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the vision-correcting intraocular lens (IOL).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Holster for use with electric or
electric/pneumatic ventricular assist device, replacement only (Q0498).

You asked the Plan to waive the coinsurance for the Holster for use with electric or electric/pneumatic
ventricular assist device, replacement only. You say that you were told you would not be charged a copayment.
The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for each Medicare-covered prosthetic device, including replacement or repairs of such devices and
related supplies.

You have been asked to pay a 20% coinsurance for Holster for use with electric or electric/pneumatic
ventricular assist device. Holster for use with electric or electric/pneumatic ventricular assist device falls within
the Prosthetic Devices and Related Supplies 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 the Holster for use with electric or electric/pneumatic ventricular assist device, replacement only (Q0498).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care.

You asked the Plan to pay for the physician services. You say that the medically necessary services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on September 3, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure. You say that your enrollment booklet state that routine preventive dental services are completely covered for both in-network and out-of-network providers. The Plan denied your request. The Plan says the total liability amount of $160.00 was applied correctly. The Plan also says that member liability is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on September 3, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).

You asked the Plan to pay for the neuromuscular stimulator (E0745). You say that these services were medically necessary. The Plan denied your request. The Plan says the neuromuscular stimulator was not medically necessary.

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 pay for the neuromuscular stimulator (E0745). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. However, there is insufficient documentation of a credible evaluation and physical examination of the ankles and feet having occurred.

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 neuromuscular stimulator (E0745) have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for paravertebral facet joint injections (64494).

You asked the Plan to pay for paravertebral facet joint injections. You say that the medical records document
that these procedures were performed. The Plan denied your request. The Plan says the billed units exceed
MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 64494 is 1. You billed two units of this code, exceeding the MUE. Based
on this information, we decided that Medicare rules for coverage of paravertebral facet joint injections have not
been met. Therefore, we decided that the Plan does not have to pay for paravertebral facet joint injections
(64494).