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

We decided that the Plan does not have to waive the cost-shares for a colonoscopy (45380) and an esophagogastroduodenoscopy (43239) provided on September 2, 2020.

You asked the Plan to waive the cost-shares for a colonoscopy and an esophagogastroduodenoscopy. You say that prior to the procedures, the enrollee was advised of her cost-shares. After the procedures were completed, the enrollee received a bill for an increased amount. The Plan denied your request. The Plan says the cost-shares the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollee must pay $1000 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The enrollee's contract with the Plan also clearly says that after you pay your $1,000 deductible, you pay a $250 copayment for each outpatient surgery.

The enrollee has been asked to pay a $1,000 deductible and $250 copayment for a colonoscopy and an esophagogastroduodenoscopy. At the time this claim was processed, the enrollee had met $0 of her $1,000 deductible. The allowed amount of the colonoscopy and the esophagogastroduodenoscopy is $1250, resulting in a deductible amount of $1,000 and a copayment of $250. The enrollee's total cost-sharing obligation is therefore $1,250. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible and a $250 copayment for each outpatient procedure, after the deductible is met. A colonoscopy and an esophagogastroduodenoscopy fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost-shares for a colonoscopy (45380) and an esophagogastroduodenoscopy (43239) provided on September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (CPT 77062) provided to the enrollee on June 12, 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 this code is not valid for Medicare purposes.

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 77062 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 imaging services (CPT 77062) provided to the enrollee on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunization services rendered on October 6, 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 90471 is not supported.

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 90471 is immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).

We find that CPT code 90471 is not supported in the medical record. Specifically, the records show that the services were an influenza vaccine and there is a more appropriate administration code for these services.

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 immunization services rendered on October 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on August 5, 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 the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for services rendered to individuals in custody of penal authorities.

We looked at the file and Medicare rules. The file shows that the enrollee was incarcerated during the date of service at issue. 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 emergency room (ER) services rendered on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar laminectomy procedure.

You asked the Plan to pre-approve laminectomy, facetectomy and foraminotomy (63047, 63048). You say that you have pain and problems walking. The Plan denied your request. The Plan says the records do not show if physical therapy worked, if you have trouble with muscle strength, or the previous surgery did not work.

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 laminectomy, facetectomy and foraminotomy (63048). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for lumbar laminectomy not met. There is no documentation of a recent and adequate trial of physical therapy for back pain. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laminectomy, facetectomy and foraminotomy (63047, 63048) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminectomy procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care rendered on November 18, 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 99305 is not supported.

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 99305 is Level 2 initial nursing facility care for evaluation and management of patient with problem of moderate severity, including comprehensive history and physical examination, and medical decision-making of moderate complexity, typical time 35 minutes.

We find that CPT code 99305 is not supported in the medical record. Specifically, the records do not support the Level 2 complexity of care. 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 nursing facility care rendered on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on August 20, 2020.

You asked the Plan to pay for therapeutic activities. You say that this should be covered. The Plan denied your
request. The Plan says this was not billed 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 therapeutic activities, direct (one-on-one) patient contact (use of
dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that this
service was performed in a home health setting. There is a more appropriate code for this service. Based on this
information, we decided that Medicare rules for coverage of therapeutic activities have not been met.
Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on August
20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a
pneumatic appliance (E0667) to be provided by an out-of-network provider.

You asked the Plan to pre-approve a pneumatic compression device and a pneumatic appliance. You say that
the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for
out of network care have not been met.

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 pneumatic compression device (E0652) and a pneumatic appliance (E0667) to be provided by an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous neuromodulation therapy (PNT).

You asked the Plan to pre-approve PNT. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that providers are to use CPT Code 64999 for both the trial and permanent insertion of the electrode array when billing for the procedures associated with either Peripheral Subcutaneous Field Stimulation or Peripheral Nerve Field Stimulation. 64999 for these purposes is not covered due to insufficient peer reviewed data to warrant the medical necessity of coverage. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PNT have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous neuromodulation therapy (PNT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair lift (E1399) with installation.

You asked the Plan to pre-approve this item. You say that a wheelchair lift is necessary for the transportation of your wheelchair. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.

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 and is not appropriate for use in your home. Although this item may be appropriate for you, coverage is not provided by the Plan or by Medicare. Therefore, we decided that the Plan does not have to pre-approve a wheelchair lift (E1399) with installation.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way transportation trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 11, 2020.

You asked the Plan to pay for the office visit. You say that he has the equipment that you need to treat your condition. The Plan denied your request. The Plan says the service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

We looked at the file and the rules. The records show that the service at issue is not manual manipulation of the spine. The office visit, when provided by a chiropractor, is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection (J0897) provided on July 16, 2020.

You asked the Plan to waive the coinsurance for a denosumab injection. You say that you have received these injections in the past and you think you should not have a coinsurance. The Plan denied your request. The Plan says the copayment you are being charged is 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for a denosumab injection. The allowed amount of the claim is $4,029.20, resulting in a coinsurance obligation of $805.84. A denosumab 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 a denosumab injection (J0897) provided on July 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six physical therapy and six occupational therapy home health services.

You asked the Plan to pre-approve six physical therapy and six occupational therapy home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 six physical therapy and six occupational therapy home health services. Our reviewer says that the documentation does not support that the requested services are medically necessary. Our physician reviewer found you have had prior therapy, but the documentation is not clear on the quantity or details of the prior therapy and the physical exam deficits do not appear to show that you require additional therapy services. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Therefore, you do not meet criteria for the requested 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 six physical therapy and six occupational therapy home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve six physical therapy and six occupational therapy home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right stab phlebectomy for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested procedure has not been met.

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 procedure. Our reviewer says that the requested services 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. Specifically, the documentation does not demonstrate symptoms of the severity to interfere with her daily activities or mobility. Additionally, while the enrollee was provided with a prescription for medical grade compression stockings, these have not yet been trialed in a concerted effort at conservative treatment. The enrollee's previous attempts with compression stockings in the past do not satisfy the coverage criteria. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a right stab phlebectomy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311).

You asked the Plan to pre-approve an expandable controller with expandable harness and electronic connection. You say that the requested features are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

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 expandable controller with expandable harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to self-feed indicates that the enrollee can control any power options through their own individual switches.

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 expandable controller with expandable harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (80074, 82306, 82607, 82728, 82746, 83036, 83540, 84466) provided on April 30, 2020.

You asked the Plan to pay for laboratory testing. You say that these tests should be covered. The Plan denied your request. The Plan says these were screening tests.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing (80074, 82306, 82607, 82728, 82746, 83036, 83540, 84466) provided on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for knee replacement surgery, an implantable joint device and physical therapy visits provided on December 11, 2020, to January 14, 2021.

You asked the Plan to waive the cost-shares for knee replacement surgery, an implantable joint device and physical therapy visits. You say you were told you owed $100 for the knee replacement surgery. You also say that you have a $0 copayment for office visits. 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 $100 copayment for outpatient hospital services. Your contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for prosthetic devices and related supplies. Your contract with the Plan also clearly says that enrollees must pay a $20 copayment for each outpatient rehabilitation service.

You have been asked to pay a $100 copayment for knee replacement surgery, a 20% coinsurance for an implantable joint device and a $20 copayment for each physical therapy visit.

The EOC confirms that $100 is the required copayment for an outpatient surgery or procedure such as knee replacement surgery.

The allowed amount of the claim for the implantable joint device is $5,851.58, resulting in a coinsurance obligation of $1,170.32. You have been asked to pay a 20% coinsurance for each prosthetic device and related supplies.

The EOC also confirms that $20 is the correct copayment for each physical therapy visit (20 x 4 visits = $80).

Your total cost-share amount is $1350.32 ($100 + $1,170.32 + $80 = $1,350.32). 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 knee replacement surgery (27447), an implantable joint device (C1776) and four (4) physical therapy visits (97112, 97110) provided on December 11, 2020, to January 14, 2021.