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

We decided that the Plan does not have to pay for common procedural terminology (CPT) codes 99291, 36556, and 36620 billed for dates of service January 14 - January 21, 2021.
You asked the Plan to pay for CPT codes 99291, 36556, and 36620. You say that the documentation submitted supports the CPT codes in dispute. The Plan denied your request. The Plan says the provider has not substantiated their billing of the CPT codes in dispute.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 36556 is insertion of a non-tunneled centrally inserted central venous catheter; age 5 years or older. The CPT Code Manual definition of code 36620 arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous. We find that CPT codes 99291, 36556, and 36620 are not supported in the medical record. The records provided show that the enrollee presented to the emergency room on January 14, 2021, with mental status changes, hyperkalemai, acute kidney injury, and an elevated brain natriuretic peptide of 18,659. A chest x-ray demonstrated bilateral opacities. The enrollee was negative for a pulmonary embolism on Computed Tomography Angiography (CTA). The enrollee was admitted for treatment of congestive heart failure versus bilateral pneumonia. The records provided did not support that the CPT codes in dispute were provided on the dates of service being billed. Based on this information, we decided that Medicare rules for coverage of CPT codes 99291, 36556, and 36620 have not been met. Therefore, we decided that the Plan does not have to pay for common procedural terminology (CPT) codes 99291, 36556, and 36620 billed for dates of service January 14 - January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total shoulder arthroplasty (23472).
You asked the Plan to pre-approve total shoulder arthroplasty. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried physical therapy.
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 total shoulder arthroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted records do not include detailed documentation regarding a trial and failure of recent, reasonable, and comprehensive conservative care measures including physical therapy. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of total shoulder arthroplasty have not been met. Therefore, we decided that the
Plan does not have to pre-approve total shoulder arthroplasty (23472).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visits provided from January 15, 2021, to
April 30, 2021, by an OON provider.
You asked the Plan to pay for the psychotherapy visits. You say that the services were medically necessary.
The Plan denied your request. The Plan says there is no coverage a non-authorized service from a noncontracted
provider.
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. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the psychotherapy visits provided from January 15, 2021, to
April 30, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on February 19, 2021.
You asked the Plan to waive the copayments for the ambulance rides. You say that you were not informed of the copayments. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip.
You have been asked to pay a $250 copayment for each of the ambulance rides on the same date of service. The ambulance rides fall 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 copayments for the ambulance rides provided on February 19, 2021.
Your complaint that the ambulance trips could have been avoided if the cast was replaces properly is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses frames (V2020) provided by February 16, 2021

You asked the Plan to pay for eyeglasses frames. You say that the enrollee did not have a choice of providers. The Plan denied your request. The Plan says this is not covered.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the item at issue when it is provided by a network optical provider. 

We looked at the file and the Plan's rules. The frames at issue were not provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses frames have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses frames (V2020) provided by February 16, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that this device would help improve the enrollee's safety. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided on November 2, 2020, through November 5, 2020.

You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not support a primary diagnosis of COVID-19.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with U07.1. 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 hospital services. Our reviewer says that the review has determined that the documentation did support DRG 177 with a primary diagnosis for COVID-19. Our physician reviewer found the records show that the member tested positive for COVID-19 on screening. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on November 2, 2020, through November 5, 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 the continuous glucose monitoring system provided on January 13, 2021.
You asked the Plan to pay for the continuous glucose monitoring system (K0553, K0554). You say that the Plan should pay this claim. The Plan denied your request.
The Plan says the enrollee elected hospice and documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code.
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 continuous glucose monitoring system provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 7, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 7, 2021, forward. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from September 7, 2021, forward. Our reviewer says that you do not meet the criteria for continued treatment in an acute inpatient mental health treatment beyond the date in question of September 7, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 7, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from September 7, 2021, forward. have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 7, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation and a follow-up visit (99204, 99214) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office consultation and a follow-up visit. You say that the member had hernia surgery 10 years ago and the surgeon told the member that if she had any issues in the future, to return to the provider as he knows how to work on the member. You also say that the member had a scan last week and 7 new hernias were discovered. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office consultation and a follow-up visit (99204, 99214) to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the enrollee has undergone conservative treatments for their lymphedema. The Plan denied your request. The Plan says the enrollee's doctor's medical notes and physical exam did not show that the enrollee has chest/abdomen (stomach) swelling. In addition, Medicare requires that the enrollee has a four-week trial of conservative therapy showing that the enrollee failed to respond to treatment and that other devices described by codes E0650 or E0651 are required. The Plan states the request is for an out-of-network DME provider and all DME must be with an in-network provider.

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 DME. Our physician reviewer found the enrollee has worsening edema in both legs with complaints of pain, numbness/tingling, and change in skin color who was seen by Vascular Surgery. The enrollee is unable to control swelling, has complication of impaired range of motion (ROM)/mobility, pain, trunk/chest/abdominal swelling and failed home therapy of banding, garments, exercise, and elevation for at least four (4) weeks. Medicare requires that the enrollee has had a four-week trial of conservative therapy showing that they failed to respond to treatment and that other devices described by codes E0650 or E0651 are required. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received from February 1, 2021, to May 31, 2021.
You asked the Plan to waive the coinsurance for the dialysis services. You say that no one explained how dialysis claims would be covered. You said that if you had known the claims would only be covered at 80%, you would not have enrolled in the plan. The Plan denied your request. The Plan says you were charged this coinsurance 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% coinsurance for dialysis services.
You have been asked to pay 20% coinsurance for the dialysis services. 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 dialysis services you received from February 1, 2021, to May 31, 2021.
Your complaint about how this plan was marketed to you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for an established patient provided on June 10, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan also says that services performed by out of network providers are not covered.
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 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 home visit for an established patient provided on June 10, 2020 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 8, 2021.

You asked the Plan to pay for the services provided. You say that your husband took you to the hospital
because you no longer felt any discomfort. The Plan denied your request. The Plan says the claim denied
correctly.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on April 8, 2021. Per authority granted under the
American Rescue Plan Act of 2021, the Centers for Medicare and Medicaid Service (CMS) has waived the
requirements that an ambulance service must include transport to allow for treatment in place when
transportation was not provided based on community-wide emergency medical service (EMS) protocols.
However, this requires that the ambulance provider submit a claim for payment under this waiver. You may
wish to contact the ambulance provider in this case to request that a new claim be submitted for payment.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 18, 2021, by an OON
provider.
You asked the Plan to pay for the office visit. You say that the service is medically necessary. The Plan denied
your request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the service at issue was urgent or
emergent. 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 visit provided on January 18, 2021, by an OON
provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310) provided April 17, 2021.
You asked the Plan to pay for endodontic therapy. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the maximum benefit limit has been reached.
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. The Plan covers up to $1000 worth of dental services. We looked at the file, and Medicare rules. In this case, the Plan has met the annual maximum for dental services of $1000. The remaining services must be paid out of pocket. Based on this information, we decided that the Plan's rules for coverage of endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3310) provided April 17, 2021.