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

We decided that the Plan does not have to pay for the percutaneous access and closure services provided on October 20, 2020.

You asked the Plan to pay for the percutaneous access and closure 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 claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 34713 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the percutaneous access and closure services have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous access and closure services provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6740 x2), and pontic (D6245) provided on December 8, 2020.

You asked the Plan to pay for retainer crowns), and pontic. You say that you were told by the provider that the services would be covered, and you want the Plan to pay. The Plan denied your request. The Plan says the services at issue are not covered 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. 

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. Therefore, we decided that the Plan does not have to pay for retainer crowns (D6740 x2), and pontic (D6245) provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vaccination services (90688, G0008) provided on October 22, 2020.

You asked the Plan to pay for vaccination services. You say that the enrollee could not leave the facility to receive the vaccine. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that when vaccines are provided to inpatients of a hospital or SNF, they are covered under the vaccine benefit. A SNF submits type of bill 022x for its Part A inpatients. 

We looked at the file and Medicare rules. The vaccine services at issue were billed with type of bill 0213, but type of bill 022x is required. Based on this information, we decided that Medicare rules for coverage of vaccination services have not been met. Therefore, we decided that the Plan does not have to pay for vaccination services (90688, G0008) provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99213) provided on February 1, 2021, by an out-of-network provider.

You asked the Plan to pay for the office services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 office services (CPT code 99213) provided on February 1, 2021, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic exercises (97110) provided November 2, 2020 to February 1, 2021.

You asked the Plan to waive the copayment for the physical therapy services. You say that you are 89 and the spine doctor is having you go to therapy. You are paying $15 each time and feels these are excessive and wishes some of these waived. 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 $15 for each Medicare covered physical therapy visit.

You have been asked to pay $15 for the physical therapy services. The physical therapy services fall within the Outpatient rehabilitation 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 therapeutic exercises (97110) provided November 2, 2020 to February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 27, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 April 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for breast biopsy surgery provided on February 8, 2021.

You asked the Plan to waive the co-payment for surgery. You say that you are on a fixed income and this is difficult to afford. The Plan denied your request. The Plan says the co-payment 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $350 co-payment for outpatient surgery at an outpatient hospital.

You have been asked to pay $350 co-payment for surgery. Surgery falls 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 waive the co-payment for breast biopsy surgery provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on January 11, 2021.

You asked the Plan to waive the copayment for vision services. You say that you go every year due to your lazy eye. You say that you have never been charged in the past for this. 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 $40 copayment for vision care/diagnose and/or treat a disease or condition of the eye.

You have been asked to pay a $40 copayment for vision services. The correct copayment has been applied to the services that were provided. Vision services fall within the vision care/diagnose and/or treat a disease or condition of the eye 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 vision services provided by a participating provider on January 11, 2021.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for aspiration pneumonia. Medical conditions 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. 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. 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-rays provided on February 22, 2021, and February 24, 2021.

You asked the Plan to pay for the services provided. You say that you are being charged for necessary services the plan does not provide. The Plan denied your request. The Plan says the services are excluded from coverage.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. These services, when provided by a chiropractor, are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the office visit and x-rays provided on February 22, 2021, and February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the back brace provided on January 4, 2021.
You asked the Plan to waive the cost share for the back brace. You say that you cannot afford to pay the copays. The Plan denied your request. The Plan says the claim was 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 20% of the total cost for prosthetic devices. You have been asked to pay 20% of the total cost for the back brace. The back brace falls within the prosthetic devices 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 back brace provided on January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable gaseous oxygen system (CPT
code E0431RR) and oxygen concentrator (CPT Code E1390RR) rental provided on January 11, 2021, by an innetwork
provider.

You asked the Plan to waive the coinsurance for the DME. You say that you were told it would be $19 a month
and you do not understand why you are being charged double. The Plan denied your request. The Plan says the
claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you rented a portable gaseous oxygen system (CPT code E0431RR) and oxygen
concentrator (CPT Code E1390RR) on January 11, 2021, from an in-network provider. You have been asked to
pay 20% coinsurance of the allowed amount for the portable gaseous oxygen system (CPT code E0431RR). The allowed amount is $19.83. The total you owe is $3.97 ($19.83 x 20% = $3.97). You have been asked to pay 20% coinsurance of the allowed amount for the oxygen concentrator (CPT Code E1390RR). The allowed amount is $20.65. The total you owe is $177.48 ($103.26 x 20% = $20.65). Your total cost share responsibility is $24.62 ($20.65 + $3.97 = $24.62). Your 2021 EOC states that enrollees must pay 20% coinsurance for in-network Medicare-covered equipment and supplies. 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 portable gaseous oxygen system (CPT code E0431RR) and oxygen concentrator (CPT Code E1390RR) rental provided on January 11, 2021, by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 22, 2020, by an OON
provider.

You asked the Plan to pay for the OON services. You say that you were not aware of the requirement of
obtaining prior authorization. The Plan denied your request. The Plan says the services were 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the lab services provided on December 22, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the magnetic resonance imaging (MRI) of upper extremity provided December 23, 2020.

You asked the Plan to waive the co-payment for the MRI of upper extremity. You say that you believe you were not primarily informed of your co-payment. The Plan denied your request. The Plan says the co-payment has processed correctly at this time.

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 $150 co-payment for Diagnostic Radiological Services.

You have been asked to pay a $150 co-payment for MRI of upper extremity. This service falls within the Diagnostic Radiological 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 co-payment for the magnetic resonance imaging (MRI) of upper extremity provided December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit on January 22, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you did not have an appointment with a doctor that day. The Plan denied your request. The Plan says you were charged this copayment 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 $25 copayment for Specialty Care Physician.

You have been asked to pay a $18.56 copayment for the office visit. The office visit falls within the Specialty Care Physician benefit category. The Medicare allowed amount for this visit is less than your required copayment. The medical record shows you had an Endocrinology office visit for pump adjustment. 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 office visit on January 22, 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 August 13, 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 August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from August 21, 2020, to August 25, 2020.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer from the emergency room.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 inpatient care. Our physician reviewer found that the enrollee was evaluated and diagnosed in the non-Plan emergency department with Covid-19 and a urinary tract infection. She was treated with intravenous antibiotics and admitted. The review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring and oxygen to a Plan facility for admission level of care services after the emergency room evaluation. There was no documentation provided necessitating post-stabilization care services at the non-Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.

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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from August 21, 2020, to August 25, 2020.