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

We decided that the Plan does not have to pay for the emergency room services provided on December 25, 2020.
You asked the Plan to pay for the emergency room services. You say that you went to the emergency room for a cut in your mouth not a dental procedure. The Plan denied your request. The Plan says the provider submitted the claim with a dental diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that ICD-10 code K06.8 is a billable diagnosis code used to specify a medical diagnosis of other specified disorders of gingiva and edentulous alveolar ridge. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on December 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) provided on January 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the eye exam. You say that the provider told you they accept your insurance for eye exams, and then told you it isn't covered after services were provided. The Plan denied your request. The Plan says out-of-network services are not covered by the Plan, except in limited circumstances. The Plan's customer service and provider directory are the best sources to verify the network status of providers.

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 eye exam (92014) provided on January 8, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for fractures of pelvis and humerus after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. You do 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. There is not a reasonable expectation that you
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to lower the co-payment for cataract surgeries performed at an outpatient hospital on January 19 and February 2, 2021.

You asked the Plan to lower the co-payment for cataract surgeries at an outpatient hospital. You say that you should have been charged a lower co-payment as stated in the Plan's EOC. The Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $345 co-payment for outpatient surgery at an outpatient hospital.

You have been asked to pay a $345 co-payment for cataract surgeries at an outpatient hospital. Cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 lower the co-payment for cataract surgeries performed at an outpatient hospital on January 19 and February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0667) for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of lymphedema of the chest, trunk, or abdomen. The documentation does not reveal unique characteristics that would indicate the requested pump over a standard pump. The documentation does not reveal that there has been a sufficient duration of a trial and failure of the standard pump.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.
You asked the Plan to pre-approve an additional twelve (12) PT visits. The Plan denied your request. The Plan says there is no documentation that supports that ongoing therapy is expected to result in continued functional improvement.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an additional twelve (12) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deteriorationof the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had 25 physical therapy treatment sessions already. The provided records indicate the enrollee has shown poor compliance with his home exercise program and "only wants massages" for the physical therapy sessions. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an additional twelve (12) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay up to the maximum benefit for the partial upper denture (D5213) provided on January 4, 2021.

You asked the Plan to pay up to the maximum benefit for the dental service. You say that your book says that you are covered for up to $1,000 for 2021. You say that you need this in order to be able to eat properly. You say that this partial will hold more teeth than your old one. The Plan denied your request. The Plan says partial upper denture is not listed as a covered service.

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 not
among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay up to the maximum benefit for the partial upper denture (D5213) provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 26, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 26, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care provided on May 18, 2020, to May 30, 2020.

You asked the Plan to pay for SNF care. You say that these services should be covered. The Plan denied your request. The Plan says that this claim was received without a charge amount.

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 rules also say that the total charges should be zero for revenue code 0022.

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 this claim was received without a charge amount, but the only claim line without a charge amount is for revenue code 0022, which requires a total charge of zero. The Plan has therefore not provided a valid denial reasoning for the services at issue. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided on May 18, 2020, to May 30, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compressor (E0651) and a pneumatic appliance (E0667) provided on November 16, 2020.

You asked the Plan to pay for a pneumatic compressor and a pneumatic appliance. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 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.

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for a pneumatic compressor (E0651) and a pneumatic appliance (E0667) provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274), the periapical x-rays (D0230 x
2), the 2D oral or facial photographic images (D0350 x 4), and the comprehensive oral evaluation (D0150)
provided on January 15, 2020.

You asked the Plan to pay for the dental services. You say that the dentist would not extract your tooth due to
your high blood pressure. You say that you found a new dentist. You say that they had to take their own x-rays.
You say that this dentist would not extract your tooth either because your blood pressure was too high. You
also say that these services should be covered. The Plan denied your request. The Plan says the provider in this
case is out of network. The Plan says that dental services performed out of network are not covered. The Plan
also that the dental services you received are not covered by Medicare, regardless of the provider's network
status.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. The record shows that the Plan offers an optional dental rider. The record also shows that you
were not enrolled in the optional dental rider on the date of service. Therefore, we decided that the Plan does
not have to pay for the bitewing x-rays (D0274), the periapical x-rays (D0230 x 2), the 2D oral or facial
photographic images (D0350 x 4), and the comprehensive oral evaluation (D0150) provided on January 15,
2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care, ED visit, and observation care discharge provided on March 7, 2019.

The enrollee asked the Plan to pay for the initial observation care, ED visit, and observation care discharge. The enrollee said that the care the enrollee received was not related to their congestive heart failure. The Plan denied your request. The Plan says the enrollee's claims would be covered by original Medicare from the date of hospice election, until the first day of the following month in which Hospice was revoked, which would have been January 01, 2021. The Plan also says that this request for reimbursement must be submitted to Original Medicare.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the initial observation care, ED visit, and observation care discharge provided on March 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80324, 80332, 80336, 80345, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 80358, 80359, 80360, 80361,80363, 80365, 80366, 80367, 80370, 80372, 80373 and 83992) provided on November 18, 2020.

You asked the Plan to pay for drug testing. You say that these codes are supported in the records. The Plan denied your request. The Plan says these codes are not valid.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 80324, 80332, 80336, 80345, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 80358, 80359, 80360, 80361,80363, 80365, 80366, 80367, 80370, 80372, 80373 and 83992 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. 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 (80324, 80332, 80336, 80345, 80346, 80348, 80349, 80353, 80354, 80355, 80356, 80358, 80359, 80360, 80361,80363, 80365, 80366, 80367, 80370, 80372, 80373 and 83992) provided on November 18, 2020.