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

We decided that the Plan has to waive the copayment for the outpatient hospital services rendered on February 17, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says that the claim was processed correctly.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the copayment was applied correctly; however, the Plan did not provide a valid Evidence of Coverage (EOC) listing your cost sharing responsibilities for review. The Qualified Independent Contractor requested this document from the Plan but a response was not received. Without the EOC, a determination based on proper cost sharing assessment cannot be supported. Therefore, we decided that the Plan has to waive the copayment for the outpatient hospital services rendered on February 17, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), the intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243), the excision of benign lesion greater than 1.25 cm (D7411), and the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) received March 29, 2021.
You asked the Plan to pay for the dental services. You say that the Plan should cover the requested services. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 intravenous moderate sedation (D9239, D9243), and the excision of benign lesion (D7411) are not among those covered under this benefit. The Plan agreed to cover the excision (D7140). You received the excision from an out-of-network provider. For excisions received from an out-of-network provider you are responsible for 55% coinsurance. In addition, when you receive services from an out-of-network provider you are responsible for the difference between the Plan's allowed amount and what was charged by the out-of-network provider. Therefore, we decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), the intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243), the excision of benign lesion greater than 1.25 cm (D7411), and the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) received March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)

You asked the Plan to pre-approve a CGM. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM.

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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

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. Based on this information, we decided that Medicare rules for
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre continuous glucose monitor (CGM)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for SNF services. 
 
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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on April 9, 2021 by an out-of-network provider.
You asked the Plan to pay for Injection, testosterone cypionate, 1 mg (J1071) and Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (96372). You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says you did not obtain prior authorization as required.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the injection provided on April 9, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from March 4, 2021, to March 25, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. You say that you were not aware that this provider was not in network. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided from March 4, 2021, to March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on December 28, 2020.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided December 29, 2020.
You asked the Plan to pay for the critical care services. You say that the coding is supported by the documentation. The Plan denied your request. The Plan says the billing of 99291 is not supported by the medical 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. We asked our coder 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 critical care services. Our reviewer says that the services provided on December 29, 2020, do not meet criteria for billing or reimbursement consideration. Our coder reviewer found that the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Per Medicare references listed below the rules state: Physicians must report services correctly. The critical care
codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician. Critical Care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. The review has determined that the medical record did not support the billing of 99291 for date of service December 29, 2020 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 critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 5, 2021.
You asked the Plan to waive the copayment for these services. You say that the provider is a level 1 provider. The Plan denied your request. The Plan says the copayment 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 $45 copayment for services received from all other specialists at an independent office.
Review of the file shows that you received dermatology services on April 5, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the services received from all other specialists at an independent office 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. The Plan confirmed that this provider is not a level 1 provider, as listed in the provider directory. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 28, 2020.

You asked the Plan to pay for lab tests. You say that the Plan has failed to make payment for these services related to the diagnosis of COVID-19. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on April 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214).

You asked the Plan to pre-approve a lower partial denture. You say that you want the Plan to cover this service. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 5 years.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service on September 13, 2019. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the
brain.

You asked the Plan to pre-approve a PET scan of the brain. 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 follows Medicare rules. Medicare rules say that a FDG PET scan is considered reasonable and
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6
months, who meet diagnostic criteria for both Alzheimer's disease (AD) and frontotemporal dementia (FTD).

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 a PET scan of the brain. Our reviewer
says that the services are not medically necessary. Our physician reviewer found in this case there is no
indication in the records that you have overlapping diagnoses of AD and FTD. You are particularly not noted to
have any symptoms to suggest the presence of FTD. As a result, it cannot be said that the requested service is
being performed in accordance with the indication for which the NCD states that this service is eligible for
coverage. Therefore, this request would not be medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan
does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services rendered on May 13, 2021.

You asked the Plan to waive the copayment for these services. You say that you shouldn't have to pay anything. The Plan denied your request. The Plan says the copayment 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 $40 copayment for in-network Medicare-covered podiatry services.

Review of the file shows that you received podiatry services on May 13, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the in-network Medicare-covered podiatry 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 podiatry services rendered on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sanuwave ultrasound.
You asked the Plan to pre-approve Sanuwave ultrasound. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 Sanuwave ultrasound. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current literature does not provide sufficient high-quality evidence to support the use of Sanuwave or similar devices for chronic foot ulcerations. Therefore, this request for such will be considered not medically necessary 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 Sanuwave ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve Sanuwave ultrasound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT).
You asked the Plan to pre-approve TTFT. 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 follows Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed Glioblastoma Multiforme (GBM) only when specific criteria are met. 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 TTFT. Our reviewer says that the services are not medically necessary. Our physician reviewer found given that the enrollee presented with a new enhancing lesion and was treated with reirradiation, the situation is consistent with recurrent disease. The enrollee does not meet the coverage criteria detailed in the NCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the practitioner services rendered on January 20, 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 procedure code 99053 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 pm and 8:00 am at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the practitioner services rendered on January 20, 2021.