Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Part B drugs you received from October
7, 2020, to October 14, 2020.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible
for the cost share.

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.

Review of the file shows that you were provided Medicare Part B drugs from October 7, 2020, to October 14,
2020. You have been asked to pay a 20% coinsurance for the drugs. The drugs fall 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 the Part B drugs you
received from October 7, 2020, to October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided February 1,
2019.
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that the copayment should be
waived. The services were provided two years ago. 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 10%
coinsurance for in-network outpatient surgical services.
You have been asked to pay a 10% coinsurance for the outpatient surgery. The outpatient surgery falls within
the in-network outpatient surgical 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 coinsurance
for outpatient surgery provided February 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99214) provided October 30, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim did not include a valid diagnosis code.
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 99214 is not supported in the medical record. Specifically, the diagnosis code listed did
not specify anatomical location. Based on this information, we decided that Medicare rules for coverage of the
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician
services (99214) provided October 30, 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).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, such as skilled nursing facility, home with home health services, or home with outpatient therapy.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of COVID 19 pneumonia, stroke, polymyositis who is living at home receiving home health physical therapy for weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on December 24, 2020.

You asked the Plan to pay for therapeutic CGM. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the record only document 1 insulin injection per day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on December 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for vacuum drainage collection unit and tubing kit (A7048)
provided October 1, 2020.
You asked the Plan to pay for vacuum drainage collection unit and tubing kit. You say that you are requesting a
reconsideration of the denial and providing adequate documentation of medical necessity of correctly reported
units for review and payment. The Plan denied your request. The Plan says the number of unites billed exceeds
the medically unlikely edit limit.
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 A7048 is 0. You billed 15 units of this code, exceeding the MUE. Based
on this information, we decided that Medicare rules for coverage of vacuum drainage collection unit and tubing
kit have not been met. Therefore, we decided that the Plan does not have to pay for vacuum drainage collection
unit and tubing kit (A7048) provided October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided by BJ's Optical, on December 4, 2020.

You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you are responsible for services received out of network for your frames and lens package. The provider is not a participating provider with your Plan.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network optical provider. 

We looked at the file and the Plan's rules. The eyeglasses were not provided by the Plan's optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the elbow surgery provided on October 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the elbow surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 elbow surgery provided on October 9, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on November 25, 2020.
You asked the Plan to pay for the AWV. The Plan denied your request. The Plan says you have exceeded the benefit limit for this service.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided on August 21, 2020, less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (AWV) you had on November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cardiac catheterization provided from October 19, 2020, to October 20, 2020.

You asked the Plan to waive the cost share for the cardiac catheterization. You say that this service should be covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible that applies towards the cardiac catheterization and 25% coinsurance for surgery services at an in-network outpatient hospital.

The cardiac catheterization you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards in-network outpatient surgery and 25% coinsurance for surgery services at an in-network outpatient hospital.

This cost sharing is a contractual obligation that had not been met at the time the cardiac catheterization was received on October 19, 2020 to October 20, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the cardiac catheterization provided from October 19, 2020, to October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve these services. You say that you need further therapy. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on October 29, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is eligible for payment as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says this testing has been determined to be not clinically valid and is non-covered.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing code 0012M is not covered by Medicare for date of service October 29, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on December 22, 2020.
You asked the Plan to pay for the resin-based composite. You say that you would like this service covered. The
Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency
limitation 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, restorations are limited to one
procedure per calendar year. The record shows that you received a resin-based composite on May 20, 2020 and
your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
resin-based composite provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on December 7, 2020.

You asked the Plan to pay for the dental service. You say that the dental hygienist explained the procedure as fluoride treatment. You say that fluoride treatment is a covered treatment in your 202 Evidence of Coverage. You also say that you believe that this was denied in error, the coding is incorrect, or the plan is misleading. The Plan denied your request. The Plan says topical application of fluoride varnish is not listed as a covered service.

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 topical application of fluoride varnish (D1206) provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of a complete upper denture (D5750), localized delivery of antimicrobial agents (D4381) and cleaning (D1110) provided on November 30, 2020.
You asked the Plan to pay for the dental services. You say that you did not know you were close to your coverage limit and expected your provider to inform you when this maximum was reached. The Plan denied your request. The Plan says coverage for dental services will only be provided up to the $850 annual maximum. You had met and exceeded this maximum as of October 2020. You are responsible for any cost above this coverage limit.
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, services and items in excess of the Plan's annual maximum of $850 will not be covered. Therefore, we decided that the Plan does not have to pay for the reline of a complete upper denture (D5750), localized delivery of antimicrobial agents (D4381) and cleaning (D1110) provided on November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart (quantitative calcium scoring) for
the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says this denial is appropriate given the clinical scenario.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 the scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the
enrollee is asymptomatic and had a calcium score of zero in 2016. She has a cardiac risk score of 21%. She
underwent an echocardiogram that was normal in 2017. The enrollee is known to have elevated cholesterol but
is not receiving treatment. The provided documentation does not indicate the medical necessity and
reasonableness of the requested test.

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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the heart (quantitative calcium scoring) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261), and related hearing services (92593, 92595, V5011) received October 29 and December 10, 2020 from an out-of-network provider.
You asked the Plan to pay for the hearing aid and related services. You say that you were informed by the Plan that you would be able to obtain coverage from an out-of-network provider. The Plan denied your request. The Plan says Hearing aids ordered through providers other than the Plan's Hearing provider are not covered, and there is no coverage if hearing aids or related services are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids and relative services only when obtained from the Plan's Hearing provider. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid and related services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid (V5261), and related hearing services (92593, 92595, V5011) received October 29 and December 10, 2020 from an out-of-network provider.
Your complaint about being informed by a customer service representative that hearing items or services obtained from an out-of-network provider would be covered is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says there is no advantage in moving from the current acute hospital to the
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. Our
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in
general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where she is currently receiving care. The clinical assessment in the case file
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services.
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee at this time.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral counseling rendered on November 23, 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 G0447 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes G0447 and 99350. Code G0447 is a column II code with a modifier indicator of 1 when billed with column I code 99350. Code G0447 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the behavioral counseling rendered on November 23, 2020.