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

We decided that the Plan does not have to pay for exchange nephrostomy and anesthesia services (procedure code 50435, 99152, 99153) provided to the enrollee on July 27, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed with the appropriate place of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of the denied codes is: 

CPT 50435: 

Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation 

CPT 99152:

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 

CPT 99153: 

Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) 

We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the provider submitted documentation showing that the enrollee was inpatient status on the dates of service at issue in this case. The description for place of service 22 (on-campus/outpatient hospital) is "A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization." Place of Service 22 would be inappropriate to report for a patient requiring hospitalization, as date of service is July 27, 2021 which falls into the inpatient status dates of service. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for exchange nephrostomy and anesthesia services (procedure code 50435, 99152, 99153) provided to the enrollee on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay up to the $150 dental allowance for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and resin-based composite (D2393) provided on June 8, 2021, and July 7, 2021.  You asked the Plan to pay up to the $150 dental allowance for the periodic oral evaluation, bitewing x-rays, prophylaxis, and resin-based composite. You say that your plan allows $150 per calendar year for dental services. The Plan denied your request. The Plan says that these services are not covered under your contract.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation, bitewing x-rays, prophylaxis, and resin-based composite have been met. The 2021 Evidence of Coverage states that the Plan offers a $150 allowance every calendar year to help you pay for dental services provided by a licensed dental provider. The record shows that proof of payment was submitted by the provider for these dental services, which are covered, and you reasonably believed the Plan would pay up to the $150 dental allowance for these services. Therefore, we decided that the Plan has to pay up to the $150 dental allowance for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and resin-based composite (D2393) provided on June 8, 2021, and July 7, 2021.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Licart (J3490).  You asked the Plan to pre-approve Licart. You say that this medication is proven safe and effective, especially versus other formulary options that the enrollee has tried and failed. The Plan denied your request. The Plan says Licart 1.3% patch is a self-administered drug. The Plan also says that this medication does not fall under Part B coverage.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Licart (J3490).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226 and 81227 provided on November 23, 2020.  

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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.  

We find that CPT codes 81225, 81226 and 81227 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Nursing facility, place of service 32. 

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81225, 81226 and 81227 provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the infusion therapy rendered from March 10, 2021 to March 31, 2021.  You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for Medicare-covered surgery or other services provided to you at outpatient hospital and a 20% coinsurance for each Medicare-covered Part B drug. You can find this information on page 4-27 of the 2021 EOC.  Review of the file shows that you received infusion therapy on March 10, 2021. Per the contract with the Plan, there is a $295 copayment for Medicare-covered surgery or other services provided to you at outpatient hospital. However, the Medicare allowed amount for these services $226.63. Given that the allowed amount was less than the $295 copayment, you have been asked to pay $226.63 for these services.  The file shows that you received Part B drug services on March 10, 2021. You have been asked to pay a 20% coinsurance for these services, for a total of $63.46. These services fall within the Medicare-covered Part B drug benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan.   The file shows that you received infusion therapy on March 17, 2021 and March 24, 2021. Per the contract with the Plan, there is a $295 copayment for Medicare-covered surgery or other services provided to you at outpatient hospital. However, the Medicare allowed amount for these services was $249.06. Given that the allowed amount was less than the $295 copayment, you have been asked to pay $249.06 per date of service for these services.  The file shows that you received infusion therapy on March 31, 2021. Per the contract with the Plan, there is a $295 copayment for Medicare-covered surgery or other services provided to you at outpatient hospital. However, the Medicare allowed amount for these services was $208.22. Given that the allowed amount was less than the $295 copayment, you have been asked to pay $208.22 for these services.  The file shows that you received Part B drug services on March 17, 2021. Per the contract with the Plan, there is a 20% coinsurance for each Medicare Part B-covered drug. However, the Plan applied a total of $57.07 coinsurance for these services, as you had met your maximum out-of-pocket amount with the processing of this claim.   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 sharing for the infusion therapy rendered from March 10, 2021 to March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a brand specific rollator (99070).  You asked the Plan to pre-approve the brand specific rollator. You say that this particular rollator best meets your needs. The Plan denied your request. The Plan says insufficient documentation has been provided to support the request.  The Plan must follow Medicare rules. Medicare rules say that contract suppliers are not required to furnish a specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome.  We looked at the file and Medicare rules. No documentation was provided to show why a standard rollator or walker would not meet this enrollee's needs. Based on this information, we decided that Medicare rules for coverage of the brand specific rollator have not been met. Therefore, we decided that the Plan does not have to pre-approve a brand specific rollator (99070).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat lift chair for the enrollee.  You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of an inability to sit or stand.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  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 chair. Our reviewer says that the requested lift chair is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee is completely incapable of standing from a chair in the home. The most up to date medical notes from 8/11/21 reports "station and gait normal, get up and go normal."  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 chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat lift chair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the seat lift mechanism incorporated into a combination lift-chair mechanism (E0627), 5-year guardsman plan (A9270), and sales tax (S9999), purchased on February 25, 2021.  You asked the Plan to pay for the seat lift mechanism incorporated into a combination lift-chair mechanism (E0627), 5-yearr guardsman plan (A9270), and sales tax. You say that the items were medically necessary. The Plan denied your request. The Plan says you do not meet the criteria for this item.  The Plan must follow Medicare rules. Medicare rules say that the practitioner ordering the seat lift mechanism must be the treating practitioner or a consulting practitioner for the disease or condition resulting in the need for a seat lift. The practitioner's record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the beneficiary to transfer from a chair to a standing position.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism incorporated into a combination Lift-chair Mechanism (E0627), 5-yearr Guardsman Plan (A9270), and Sales Tax have not been met. Specifically, you purchased this item from a furniture store without a prescription from the physician and you do not meet the criteria for a seat lift mechanism. Also, extra warranties and sales tax are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the seat lift mechanism incorporated into a combination lift-chair mechanism (E0627), 5-year guardsman plan (A9270), and sales tax (S9999), purchased on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) and the chronic care management services (99490) rendered by the out-of-network (OON) provider on July 14, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 domiciliary or rest home visit (99336) and the chronic care management services (99490) rendered by the out-of-network (OON) provider on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided June 22, 2021.  You asked the Plan to pay for the crown. You say that you were unaware that your dental benefits had changed and cannot afford the cost of the crown. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers crowns once per calendar year.  We looked at the file, and Medicare rules. The Plan provided documentation showing that one crown was covered on June 22, 2021.  Based on this information, we decided that the Plan's frequency limit for coverage of the crown has been exceeded. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided June 22, 2021.   MAXIMUS Federal Services read your letter and knows that you may have a question regarding your enrollment in the Plan.  MAXIMUS Federal Services cannot answer enrollment questions.  MAXIMUS Federal Services is sending a copy of your case file and your letter to the Kansas City CMS Regional Office, so that it can look into your enrollment question.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0425) provided on August 24, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that the cost of this service is unreasonable. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ambulance services require a $300 copayment.  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 $300 copayment for ambulance services.   You have been asked to pay a $300 copayment for the ambulance transportation.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0425) provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pulp vitality test (D0460), and consultation (D9310) provided on August 10, 2021.  You asked the Plan to pay for the dental services. You say that the services should be covered as in network due to the National Public Health Emergency. The Plan denied your request. The Plan says the pulp vitality test is not listed as a covered service. The Plan says that consultation is not listed as a covered service either.  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 pulp vitality test and consultation are not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the pulp vitality test (D0460), and consultation (D9310) provided on August 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that IRF care will help you get your strength back after having been in the hospital for 10 days. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in an alternate, less intensive setting.  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 congestive heart failure, hypertensive urgency, uncontrolled diabetes and hyperkalemia. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 22, 2021.  

You asked the Plan to waive the copayment for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the copayment was applied correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for in-network specialist's office services.   

Review of the file shows that you received specialist office services on June 22, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the in-network specialist's office services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on June 22, 2021.