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

We decided that the Plan does not have to pay for the colonoscopy services coded 45378 provided on August 1, 2020.
You asked the Plan to pay for the colonoscopy 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 supported by the documentation.
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 45378 is colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). We find that CPT code 45378 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the colonoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy services coded 45378 provided on August 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for 5 wound care treatments provided November 20, 2020 to December 23, 2020.
You asked the Plan to waive the copayments for the wound care treatments. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $295 copayment for outpatient surgery. You have been asked to pay the allowable amount of $243.05 for each wound care treatment. The wound care treatments fall within the outpatient surgery benefit category. The Medicare allowable amount is less than the $295 copayment stipulated in the Evidence of Coverage. 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 5 wound care treatments provided November 20, 2020 to December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered on December 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. 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 inpatient hospital services rendered on December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 1, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee is being billed for mystery treatment. The Plan denied your request. The Plan says these services are not a covered benefit.
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 March 1, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 1, 2020.
Sincerely,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and removal of impacted cerumen services received on October 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and removal of impacted cerumen services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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. Therefore, we decided that the Plan does not have to pay for the office visit and removal of impacted cerumen services received on October 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4341 x4) and four gingival irrigations (D4921 x4) provided on September 25, 2020.

You asked the Plan to pay for the scalings and planings and gingival irrigations. You say that you were advised that you insurance would cover the dental treatment. The Plan denied your request. The Plan says these services are not covered.

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 the four periodontal scalings and root planings (D4341 x4) and four gingival irrigations (D4921 x4) provided on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external ambulatory infusion pump for insulin.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria is not met.
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 pump. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are a 56 year old male with type 2 diabetes mellitus for which you take glipizide ER, metformin, and one injection of long-acting insulin (Basaglar) per day. Glucose is being checked once daily only. An insulin pump was requested. No C-peptide level provided in the records. Based on this information, you do not meet the criteria for the pump. You are not not checking glucose or administering insulin frequently enough and do not have evidence of low insulin production. 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 pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory infusion pump for insulin.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 29, 2019, to July 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that 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 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 physician services provided on January 29, 2019, to July 3, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for after-cataract laser surgery (66821) performed on September 14 and November 9, 2020.
You asked the Plan to waive the copayments for after-cataract laser surgery. You say that the requested services were not outpatient surgery but rather 1-minute procedures with no prep. The Plan denied your request. The Plan says the correct copayments were 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 $395 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center. You have been asked to pay a $236.63 copayment for each date of service for after-cataract laser surgery. After-cataract laser surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay less than or equal to 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 after-cataract laser surgery (66821) performed on September 14 and November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from March 13, 2019, through March 15, 2019 with the reported diagnosis I50.33, acute on chronic diastolic (congestive) heart failure.

You asked the Plan to pay for the inpatient services provided from March 13, 2019, through March 15, 2019 with the reported diagnosis I50.33, acute on chronic diastolic (congestive) heart failure. The Plan denied your request. The Plan says the documentation and clinical evidence available for review fail to support an exacerbation of CHF.

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 diagnosis code I50.33, acute on chronic diastolic (congestive) heart failure. 

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 services provided from March 13, 2019, through March 15, 2019 with the reported diagnosis I50.33, acute on chronic diastolic (congestive) heart failure. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation indicates that the enrollee presented to the facility on March 13, 2019 for the treatment of dyspnea. In this case, on presentation the BNP was elevated to 1707. However, there are limitations to the use of BNP for the diagnosis of HF. Patients with chronic HF may have persistently elevated BNP concentrations, and therefore, an elevated BNP in these patients does not rule out other causes for their dyspnea. Therefore, plasma BNP can support a HF diagnosis but cannot confirm an acute deterioration. In addition, the physician indicated in the discharge summary that the "BNP is not elevated given her age". The enrollee was treated with a one-time dose of IV Lasix in the ER. The physician stated that the primary source of the enrollee's dyspnea on exertion was the respiratory infection and likely reactive airway disease. The review has determined that the diagnosis code I50.33, acute on chronic diastolic (congestive) heart failure, was not supported by the medical records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from March 13, 2019, through March 15, 2019 with the reported diagnosis I50.33, acute on chronic diastolic (congestive) heart failure.
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 surgical repair of an ankle fracture after a fall. 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. 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 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 pre-approve a referral to an out-of-network pain management
specialist.
You asked the Plan to pre-approve these services. You say that you need treatment for low back pain. The Plan
denied your request. The Plan says the services are available from network 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 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. 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
a referral to an out-of-network pain management specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided on August 3, 2020 by an out of network provider.
You asked the Plan to pay for the interrogation device evaluation (93296). You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation provided on August 3, 2020 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital administration of Ocrevus (J2350, 96413, 96415) provided on September 22, 2020.
You asked the Plan to waive the coinsurance for administration of Ocrevus. You say that that you cannot afford to pay this bill. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for services rendered to enrollees in the outpatient department of a hospital. You have been asked to pay $427.34, or 20% of the Medicare-allowed amount of $2,136.70, for drug administration services, and $3,140.68, or less than or equal to 20% of the Medicare-allowed amount of $43,476.06 for the drug Ocrevus. Outpatient hospital administration of Ocrevus falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay less than or equal to 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 outpatient hospital administration of Ocrevus (J2350, 96413, 96415) provided on September 22, 2020.
Your complaint about the Plan instructing you to receive administration of Ocrevus in an outpatient hospital setting 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on February 1, 2021.
You asked the Plan to pay for the services. You say that this was an emergency. The Plan denied your request. The Plan says this is not a covered benefit.
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. Therefore, we decided that the Plan does not have to pay for the services you received on February 1, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
You asked the Plan to pre-approve the knee MRI. You say that it is felt that this MRI would be beneficial to determine whether physical therapy would be helpful or if orthopedic consultation is required. The Plan denied your request. The Plan says the enrollee must undergo a trial of physical therapy before receiving an MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 knee MRI. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found the enrollee is a 71-year-old woman who has been experiencing severe right knee pain since she bent down and heard a pop in her knee. The provider performed an x-ray which only showed mild arthritis in her knee. Musculoskeletal emergencies that require an immediate MRI are limited primarily to spinal conditions such as suspected cauda equina syndrome and infection. There are certain acute neck, back, shoulder, and knee conditions for which MRI should be considered after four to six weeks of conservative care if the findings could alter treatment. Since there has been no six-week trial of conservative care, this imaging is not warranted at this time. 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 knee MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on June 18, 2020.
You asked the Plan to pay for the dental services. You say that this provider had a special arrangement with your plan so that you could continue seeing him. You say that you were advised the plan had paid for services provided on June 17, 2020, and June 18, 2020 but not any other dates of service after. You also say that you were advised services should be covered up until June 31, 2020. The Plan denied your request. The Plan says 1 periapical x-ray is covered per year. The Plan also says that the frequency limit has 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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on June 17, 2020. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on June 18, 2020.