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

We decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (22514).
You asked the Plan to pre-approve a percutaneous vertebral augmentation (22514). You say that the requested percutaneous vertebral augmentation (22514) is medically necessary The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested percutaneous vertebral augmentation (22514).
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 a percutaneous vertebral augmentation (22514). Our reviewer says that the enrollee does not meet criteria for the requested percutaneous vertebral augmentation (22514). Our physician reviewer found the enrollee has a long history of back pain. There is no definite evidence of an acute fracture on MRI. There is no dexa report or documentation of osteoporosis evaluation. Recent literature show that kyphoplasty is not more effective than sham treatment. Also, there has not been an adequate trial of brace use. 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 percutaneous vertebral augmentation (22514) have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous vertebral augmentation (22514).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection (J0897).

You asked the Plan to waive the coinsurance for a Prolia injection. You say that you were told this would be covered. The Plan denied your request. The Plan says this processed 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 Medicare Part B injectable drugs. 

You have been asked to pay a $262.56 coinsurance ($1,312.81 allowed amount x 20% = $262.56) for a Prolia injection. 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 Prolia injection (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99335) provided on October 5, 2020.

You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because the member was seen by multiple providers on the same date of service. The Plan denied your request. The Plan says 99335 was billed and paid for the same date of service by the same provider.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We find that CPT code 99335 is not supported in the record. Specifically, CPT code 99335 has a MUE of 1 and MAI of 3 meaning that the medical necessity of additional units must be supported in the medical record. The record shows that CPT code 99335 has ben previously processed and paid to this provider. The documentation submitted does not include any clinical information to verify the medical necessity of the additional units billed by the same provider. Based on this information, we decided that Medicare rules for coverage of the nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility care (99335) provided on October 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 15, 2020, to December 17, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you were told that you could not take your own medications, and had no choice in taking the medications from the hospital. The Plan denied your request. The Plan says self-administered medications not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from December 15, 2020, to December 17, 2020.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.

You asked the Plan to pay for the ambulance services. You say that you did not request this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on November 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) provided on December 2, 2020.

You asked the Plan to pay for the cleaning. You say that for the first two months of the year, you participated in the Plan's additional optional supplemental dental benefit. You feel that your first cleaning should have been counted differently as it was done while you were enrolled in extra benefits, and the cleaning should count towards your current benefit. The Plan denied your request. The Plan says only two standard cleanings are covered per year. This is true for both the mandatory dental benefit and the optional benefit. The mandatory benefit offers primarily preventative and routine services. The optional benefit offers a range of comprehensive services (such as dentures, root canals, fillings and crowns) that are not covered by the mandatory benefit, but does not offer a greater number of cleanings within a year.

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 were provided in a greater frequency than the benefit allows. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) provided on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on October 5, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that you were informed you would owe nothing for an endoscopy. You say that you do not owe the $325 billed. The Plan denied your request. The Plan says the copayment 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 $325 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $325 copayment for the endoscopy. The endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The endoscopy is considered a surgical service. 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 endoscopy provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered screening testing services (CPT code(s): 87491, 87591, 87624) provided to the enrollee on August 19, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says these services are not authorized because predictive screening testing is not a Medicare benefit.

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, the services, 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 non-covered screening testing services (CPT code(s): 87491, 87591, 87624) provided to the enrollee on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on September 6, 2020.

You asked the Plan to waive the copayment for the specialist visit. You say that this copayment should be waived because you were billed for the emergency visit. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered visit or consultation in an outpatient location with a specialist.

You have been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist visit provided on September 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 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 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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray rendered on October 28, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the denial. 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 $15 copayment for each x-ray service.

Review of the file shows that you had an x-ray on October 28, 2020. You have been asked to pay a $15 copayment for these services. These services fall within the x-ray service 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 x-ray rendered on October 28, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of tunneled central venous catheter (36589) provided on May 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the removal of tunneled central venous catheter. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not obtain prior authorization for the billed service.

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 removal of tunneled central venous catheter (36589) provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 4, 2020, to September 19, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from August 13, 2020, to January 4, 2021. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 4, 2020, to September 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the requested items were medically necessary. The Plan denied your request. The Plan says the patient did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, and there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 22, 2020.

You asked the Plan to waive the copayment for ambulance transport. You say that you do not want to pay this copayment. The Plan denied your request. The Plan says the copayment amount 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 $395 copayment for one-way ground ambulance trip. 

You have been asked to pay $395 copayment for ambulance transport. Ambulance transport falls within the Ambulance 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 ambulance transportation provided on August 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face down recovery equipment provided on December 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the face down recovery equipment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this equipment was supplied by an out-of-network provider, was not urgent, emergent or approved in advance.

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 face down recovery equipment provided on December 1, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance service and inpatient hospital services provided June 9, 2020 to June 17, 2020.

You asked the Plan to waive the copayment for the emergency ambulance and hospital services. You say that you should not have to pay because you did not call for an ambulance and you were there only for blood transfusion but was sent to the rehab center due to internal bleeding. The Plan denied your request. The Plan says the claims were processed and the correct copayment was applied per the Evidence of Coverage.

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 $492 copayment each day for days 1-4 and $0 copayment for each additional day for each inpatient stay and $395 for each one-way trip by ground ambulance for Ambulance services and Inpatient hospital care. 

You have been asked to pay $2363 ($395 + $1,968.00 ($492 x 4 days) for the ambulance and hospital services. The ambulance and hospital services fall within the Ambulance services and Inpatient hospital care benefit categories. 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 emergency ambulance service and inpatient hospital services provided June 9, 2020 to June 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on June 29, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted documentation indicates that the specimen was collected in an office setting.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, this claim was billed with a laboratory place of service code but the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0483) provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) scan of the brain stem (70551) provided on December 22, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $50 copayment for each covered diagnostic procedure or test at a network outpatient facility. 

You have been asked to pay a $50 copayment for the diagnostic test provided at a network outpatient facility. 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 magnetic resonance imaging (MRI) scan of the brain stem (70551) provided on December 22, 2020.