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

We decided that the Plan does not have to pay for the anesthesia services coded 01610.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 01610 is anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla.

We find that CPT code 01610 is not supported in the medical record. Specifically, the documentation does not support that a physician's order was given, how the enrollee came to the provider, or whether the services provided were necessary. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. No medical records were provided to the plan to support the services billed. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01610.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0230, D0220) and does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D110), bitewing radiographic images (D0274), and an intraoral periapical radiographic image (D0230).

You asked the Plan to pay for intraoral periapical radiographic images and to pay an additional amount for a periodic oral evaluation, teeth cleaning, bitewing radiographic images, and an intraoral periapical radiographic image. You say that it is in the patient's best interest that they continue care with this provider and are requesting the claim to be paid in full. The Plan denied your request. The Plan says the Plan provides coverage for one intraoral periapical radiographic image per calendar year. The frequency limitation was exceeded for the additional two intraoral periapical radiographic images. The services were processed correctly according to the Plan's out-of-network benefits.

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 intraoral periapical radiographic images and to pay an additional amount for a periodic oral evaluation, teeth cleaning, bitewing radiographic images, and an intraoral periapical radiographic image have not been met. Specifically, the record shows that the patient had exceeded the frequency limit for the intraoral periapical radiographic images. A total of three intraoral periapical radiographic images. The Plan provides coverage for one intraoral periapical radiographic image per calendar year. The periodic oral evaluation, teeth cleaning, bitewing radiographic images, and an intraoral periapical radiographic image were processed correctly for out-of-network benefits. Therefore, we decided that the Plan does not have to pay for intraoral periapical radiographic images (D0230, D0220) and does not have to pay an additional amount for a periodic oral evaluation (D0120), teeth cleaning (D110), bitewing radiographic images (D0274), and an intraoral periapical radiographic image (D0230).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a an out-of-network provider.

You asked the Plan to waive the copayment for an ambulance trip. You say that you did not have a choice in the matter. You say that you would like this copayment waived. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 copayment for ambulance services/out-of-network/emergency ambulance.

You have been asked to pay a $270 copayment for an ambulance trip. There is the same copayment amount of $270 for in-network and out-of-network providers; therefore, the correct copayment has been applied. An ambulance trip falls within the ambulance services/out-of-network/emergency ambulance 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 an ambulance trip provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve a multiaxial ankle with swing phase active dorsiflexion feature (L5968). We decided that the Plan does not have to pre-approve a Flex-walk system or equal (L5981).

You asked the Plan to pre-approve a multiaxial ankle with swing phase active dorsiflexion feature (L5968) and a Flex-walk system or equal (L5981). You say that a multiaxial ankle with swing phase active dorsiflexion feature (L5968) and a Flex-walk system or equal (L5981) is medically necessary. The Plan says that a multiaxial ankle with swing phase active dorsiflexion feature (L5968) and a Flex-walk system or equal (L5981) is not medically necessary.

We decided that the Plan has to pre-approve a multiaxial ankle with swing phase active dorsiflexion feature (L5968).

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 multiaxial ankle with swing phase active dorsiflexion feature (L5968). Our reviewer says that an axial rotation unit (L5986) is covered for beneficiaries whose functional level is 2 or above. Our physician reviewer found the enrollee meets LCD criteria for this additional feature.

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 multiaxial ankle with swing phase active dorsiflexion feature (L5968) have been met. Therefore, we decided that the Plan has to pre-approve a multiaxial ankle with swing phase active dorsiflexion feature (L5968).

We also decided that the Plan does not have to pre-approve a Flex-walk system or equal (L5981).

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 Flex-walk system or equal (L5981). Our reviewer says that the documentation is insufficient to demonstrate that the enrollee in this case currently has a functional level that is 3 or above. Our physician reviewer found that the LCD criteria have not been met for this system.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Flex-walk system or equal (L5981) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flex-walk system or equal (L5981).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical implant (D6010) and an intraoral periapical radiographic image (D0220).

You asked the Plan to pay for a surgical implant and an intraoral periapical radiographic image. You say that you did not know the services would not be covered. The Plan denied your request. The Plan says implants are only a covered benefit for front teeth. The intraoral periapical radiographic image is a covered benefit, but you have exceeded the frequency limit of four in a twelve-month period.

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 intraoral periapical radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit for intraoral periapical radiographic images. Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical implant is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a surgical implant (D6010) and an intraoral periapical radiographic image (D0220).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous implantation of neurostimulator electrodes (64555, 64555 XS) and the fluoroscopic guidance (77003).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services provided were not medically necessary.

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 pay for these services. Our reviewer says that the services provided are not considered medically reasonable and necessary in this case. Our physician reviewer found that peripheral nerve stimulation for chronic shoulder pain is experimental/investigational.

We looked at this physician's review, the file, and Medicare rules. 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 percutaneous implantation of neurostimulator electrodes (64555, 64555 XS) and the fluoroscopic guidance (77003).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
October 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you don't understand 
why the Plan would not cover the entire bill. 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 $265 
copayment per date of service regardless of the number of trips for ground ambulance. 
 
You have been asked to pay a $265 copayment for the ambulance transport. The 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 
the ambulance transport provided on October 16, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the ambulance transport provided on May 14, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you were admitted to the 
hospital and not just for observation. The Plan denied your request. The Plan says that the copayment applied 
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 did not submit medical records to support only being admitted to 
outpatient observation. This means that we cannot determine if the denial is justified by the Plan contract. 
Therefore, we decided that the Plan has to waive the copayment for the ambulance transport provided on May 
14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the wound care durable medical equipment (A6252, A6531, A6261, A6449).

You asked the Plan to waive the cost share for the wound care durable medical equipment. You say that because you did not use the equipment, you would like this cost share waived. The Plan denied your request. The Plan says the cost share processed correctly and no reimbursement is due.

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 durable medical equipment.

You have been asked to pay a 20% coinsurance for the wound care durable medical equipment. The wound care durable medical equipment falls within the durable medical equipment 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 cost share for the wound care durable medical equipment (A6252, A6531, A6261, A6449).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of lumbar back 
surgery and is now living at home with weakness and trouble ambulating. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
There is no documented need for intensive rehabilitation services. There is not a reasonable expectation that 
this patient 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs a higher level of medical 
management than what is available in the lower level of care. The Plan denied your request. The Plan says the 
IRF setting is not medically necessary for this enrollee. 
 
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 patient was admitted for myocardial infarction, respiratory failure, renal failure, 
atrial fibrillation, urinary tract infection, and aspiration pneumonia. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309).

You asked the Plan to pay for subsequent nursing facility care. You say that the services provided to the enrollee are considered separate from any other facility charge or provider charge. Please review the attached medical records and reprocess for payment. The Plan denied your request. The Plan says this claim is a duplicate service billed by the same provider for the same date of service.

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 99309 is subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of moderate complexity. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit.

We find that CPT code 99309 is not supported in the medical record. Specifically, the records do not support that the service was provided more than once for this date of service by the provider. This records show this is a duplicate for services paid. Based on this information, we decided that Medicare rules for coverage of subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99309).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93042).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment.

We looked at the file and Medicare rules. Per Medicare rules, the payment for the requested services is included in the payment for the emergency services. Separate payment cannot be made for these services. 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 the services (CPT 93042).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 10, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they 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 did not pre-approve the 
physician's services. 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's services provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and 
panoramic x-ray provided on October 20, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and panoramic x-ray. You 
say that you contacted the Plan to verify your coverage prior to receiving these services. The Plan denied your 
request. The Plan says your benefits for these services have been satisfied and the frequency limitations have 
been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to one comprehensive 
oral evaluation per calendar year, one set of bitewing x-rays per calendar year, and either one panoramic or full 
mouth x-ray every five calendar years. The record shows that you received a comprehensive oral evaluation, 
bitewing x-rays, and panoramic x-ray on March 2, 2020, and your comprehensive oral evaluation, bitewing x-
rays, and panoramic x-ray benefits have been exhausted. The record also shows that on May 27, 2020 you 
contacted the Plan and were advised the Plan would not provide benefits for another comprehensive oral 
evaluation and x-rays if you proceeded to seek care from another dentist. You were also advised you would 
incur out-of-pocket expenses since the Plan benefits were exhausted for these services. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation, bitewing x-rays, and panoramic x-ray 
provided on October 20, 2020.