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

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee would strongly benefit from the services at an IRF. The Plan denied your request. The Plan says the IRF admission is not medically necessary.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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 the acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on March 8, 2021.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you have a condition that requires a diagnostic mammogram but you feel that the services should still be considered preventative. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for mammograms. The record shows that you received a diagnostic mammogram on March 8, 2021. The total allowed amount is $188.90 and 20% of that is $37.78. You have been asked to pay the total coinsurance amount of $37.78 for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you do not want to go to the skilled nursing facility due to an unsatisfactory experience you had during a prior visit. The Plan denied your request. The Plan says the clinical information submitted does not establish medical necessity.
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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. Our reviewer found that you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition, and able to be furnished safely and effectively only on an inpatient basis. 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora neurostimulator (E0745) provided August 31, 2020.

You asked the Plan to pay for the neurostimulator. You say that the neurostimulator was medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The record did not include an itemized billing or shipping invoice. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay for a neurostimulator (E0745) provided August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on December 10, 2020. You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the hearing aids were not obtained from the Plan's hearing aid 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. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 27, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that you never had to pay a bill for lab work, and you should not have to pay the copayment. 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 $5 copayment for diagnostic lab services and diagnostic procedures and tests. You have been asked to pay a $5 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0650) and a pneumatic appliance (E0669) provided on October 28, 2020.
You asked the Plan to pay for a pneumatic compression device and a pneumatic appliance. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 a pneumatic compression device and a pneumatic appliance. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found that you had leg swelling. The record sent by your provider indicated that you were in the hospital and were noted to have right leg swelling due to a previous deep vein thrombosis (DVT). The medical records did not indicate that you have chronic, severe lymphedema or venous insufficiency with ulcers. Additionally, there was no indication that your provider ordered this device, or that you have failed conservative management, used compression stockings, or had a trial of the device prior to purchase. 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 pneumatic compression device and a pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0650) and a pneumatic appliance (E0669) provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the 6 localized deliveries of antimicrobial agents (D4381 x6) provided on October 22, 2020.
You asked the Plan to pay for the localized deliveries of antimicrobial agents. You say that the provider did a cleaning and gave the shots the same day as the treatment. The Plan denied your request. The Plan says that additional payment is not available from the member or plan for the localized delivery of antimicrobial agents (D4381) when it is performed with periodontal scaling or root planing (D4341 or D4342) in the same quadrant on the same date of service. The Plan also says that the benefit maximum has been met.
The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. We looked at the file and Medicare rules. The record shows that you received 6 localized deliveries of antimicrobial agents (D4381 x6). The dental benefits addendum shows that this service is covered, and limited to once per tooth every 12 months. The EOC does not clearly state that this service is not covered when it is performed with periodontal scaling or root planing. The documentation also does not show that the benefit maximum has been met. You reasonably believed this service would be covered. Based on this information, we decided that the Plan's rules for coverage of the localized deliveries of antimicrobial agents have been met. Therefore, we decided that the Plan has to pay for the 6 localized deliveries of antimicrobial agents (D4381 x6) provided on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a needle electromyography (95886), nerve conduction studies (95910), and somatosensory testing (95938) provided on December 3, 2020.
You asked the Plan to pay for a needle electromyography, nerve conduction studies, and somatosensory testing. You say that the service was coded correctly and is reimbursable. The Plan denied your request. The Plan says rules for payment have not been met. The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In this case, the provided services were reported with the mobile unit POS code 15. The Plan has documented the services at issue were provided to the enrollee on an inpatient basis. The services at issue should be reported with the inpatient hospital POS code 21. Based on this information, we decided that Medicare rules for coverage of a needle electromyography, nerve conduction studies, and somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for a needle electromyography (95886), nerve conduction studies (95910), and somatosensory testing (95938) provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 75mg Testopel Implant Pellets.
You asked the Plan to pre-approve the Testopel Implant Pellets. You say that you would like reconsideration because this service will improve your quality of life. The Plan denied your request. The Plan says this service is excluded and non-formulary.
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Testopel Implant Pellets have not been met. Specifically, the documentation submitted does not include any clinical information. Without this information we are unable to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-approve 75mg Testopel Implant Pellets.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided on September 13, 2020.
You asked the Plan to pay for the office visit. You say that you have no other insurance. The Plan denied your request. The Plan says that the enrollee had other insurance on the date of service in dispute.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not shown that they sent the bill directly to the primary insurer, directed the provider to send the bill to the primary insurer, or paid for the services and submitted a bill for reimbursement to the primary insurer. The Plan has not made reasonable and diligent efforts to gather and forward us information that supports their having met their obligation in regard to coordination of benefits. Therefore, we decided that the Plan has to pay for an office visit provided on September 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted procedure provided on February 15, 2021.
You asked the Plan to pay for the unlisted procedure, nervous system (64999). You say that the Plan both nerve blocks were required. The Plan denied your request. The Plan says anesthesia services must be billed with 00100-01999 when billed by an anesthesia practitioner.
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 64999 is Unlisted procedure, nervous system. We find that CPT code 64999 is not payable when billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of the unlisted procedure, nervous system (64999) have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted procedure provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230 x3) received January 18, 2021.
You asked the Plan to pay for the intraoral - periapical each additional radiographic image. You say that you would not have gone to this provider if you knew they were out-of-network. The Plan denied your request. The Plan says although they agreed to reprocess the claim and cover some services, your benefit frequency limitation for intraoral images was exhausted.
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 in excess of those covered under this benefit. The Plan limits coverage of intraoral radiographic images to one procedure per year. The Plan covered the first intraoral radiographic image received on January 18, 2021; however, this exhausted your benefit for this procedure. You are responsible for the remaining three intraoral image procedures performed on this date of service. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230 x3) received January 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home dialysis services provided from January 18, 2021 to January 29, 2021. You asked the Plan to pay for the home dialysis services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program. The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home dialysis services provided from January 18, 2021 to January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management services, 30 minutes or less
(99315).

You asked the Plan to pay for discharge day management services. You say that you did not receive proper
notice of this enrollee's benefit determination, hence, the untimely submission of this claim. The Plan denied
your request. The Plan says the claim was submitted past the timely filing limitation.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for discharge day management services was not filed until February 10, 2021.
This means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for discharge day management services, 30 minutes or
less (99315).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99335) provided on December 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 services were not pre-authorized or emergent. There were network providers available.
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 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 physician services (99335) provided on December 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy outpatient visits (90837) provided on February 27, 2020, to February 25, 2021.
You asked the Plan to waive the copayment for psychotherapy outpatient visits. You say that you should not be charged a cost share for a visit with a therapist. 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 $40 copayment for each outpatient mental health care visit.
You have been asked to pay a $40 copayment for each psychotherapy outpatient visit. The records show that you had twenty-four (24) psychotherapy outpatient visits for a total cost share of $960 ($40 x 24 visits = $960). The EOC confirms that $40 per visit is the required copayment for this service. Psychotherapy outpatient visits fall within the outpatient mental health care 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 twenty-four (24) psychotherapy outpatient visits (90837) provided on February 27, 2020, to February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 24, 2020.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing aid must be purchased through the Plan's hearing aid provider to be covered.
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 only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 24, 2020.