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

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care, provided on June 1, 2021, through June 21, 2021.

You asked the Plan to waive the copayment for the SNF care. You say that there should not be any copayment. The Plan denied your request. The Plan says the cost share 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 $25 copayment each day one through twenty-one for skilled nursing facility (SNF) care. 

You have been asked to pay a $25 copayment each day one through twenty-one for the SNF care. The documentation submitted indicated you were in a skilled nursing facility for 34 day. There was no copayment for the first 20 days and you were asked to pay $25 each day for the remaining 14 days. This service falls within the skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) care, provided on June 1, 2021, through June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sedation services provided on August 23, 2021.  

You asked the Plan to pay for the services provided. You say that the claim was billed with the correct place of service. The Plan denied your request. The Plan says the services were not billed as required by coding regulations.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   

We looked at the file and the rules. We find that CPT code 99153 is a technical component only code. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the sedation services provided on August 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Reblozyl.  

You asked the Plan to pre-approve Reblozyl. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Reblozyl. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Reblozyl is medically reasonable and necessary for the enrollee. The documentation does not support that the Reblozyl is safe and effective for the enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine received on July 19, 2021.

You asked the Plan to pay for the Tdap vaccine. You say that your doctor did not say it would not be covered. The Plan denied your request. The Plan says the services received are not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine received on July 19, 2021.

Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement of the copayment for the office visit (99212) provided on June 2, 2021.  You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $45 copayment for each Medicare-covered visit with a specialist.   You have been asked to pay a $45 copayment for the Medicare-covered specialist visit provided. 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 issue reimbursement of the copayment for the office visit (99212) provided on June 2, 2021.   Your complaint that your office visit was not scheduled correctly 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 waive the copayment for the office visit (99204) provided August 6, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you do not believe you should pay the full amount based on the quality of care you received. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 $45 copayment for physician services rendered by a specialist. 

You have been asked to pay a $45 copayment for the office visit. This service falls within the physician services rendered by a specialist 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 office visit (99204) provided August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation service provided on June 15, 2021.

You asked the Plan to pay for sedation. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support the code 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 CPT Code Manual definition of code 99152 is 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.

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 sedation. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the documentation does not support requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sedation have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation service provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care visit provided on September 14, 2021.  

You asked the Plan to waive the copayment for the primary care visit. You say that you should not be charged since it could have been done at your annual exam. The Plan denied your request. The Plan says you have been charged 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 $10 copayment for each primary care physician (PCP) visit.   

You have been asked to pay a $10 copayment for the primary care visit. Primary care visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a primary care visit provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation service provided on March 4, 2021.  

You asked the Plan to pay for sedation. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support use of code 99152.  

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 99152 is 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.  

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 sedation. Our reviewer says that this code does not meet criteria for payment. Our reviewer found the clinical documentation in the Cardiac Catheterization and Peripheral Vascular Report dated 3/4/2021 does not include requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sedation have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation service provided on March 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or an assisted living facility with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Intravascular ultrasound (37253) provided on May 6, 2021.  You asked the Plan to pay for code 37253. You say that the medical records support the billing of code 37253. The Plan denied your request. The Plan says the medical records do not support the billing of code 37253.  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 37253 is  Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure).  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 code 37253. Our reviewer says that the medical records do not support the billing of code 37253. Our reviewer found based on the documentation provided, on May 6, 2021, percutaneous access to the left common femoral artery was obtained under ultrasound guidance. An abdominal aortogram and a right leg angiogram were performed. A 3rd order selective catheterization of the right popliteal artery below the knee was performed. IV ultrasound of the right common femoral artery, superficial artery, and popliteal artery was performed. The femoral popliteal territory is considered a single vessel, which includes the common femoral, profunda femoral, superficial femoral, and the entire popliteal artery. Therefore, the documentation does not support the CPT code 37253 x 2.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 37253 have not been met. Therefore, we decided that the Plan does not have to pay for the Intravascular ultrasound (37253) provided on May 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.  

You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is dependent with functional mobility and requires varying assistance with activity of daily living. The enrollee does not require skilled nursing or therapy services daily. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cataract surgery (66984) provided on August 19, 2021. 

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  

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 $325 copayment for each Medicare-covered ambulatory surgical center visit.   

You have been asked to pay a $325 copayment for the Medicare-covered ambulatory surgical center visit provided. 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 cataract surgery (66984) provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).  

You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says The pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services (88312, 88305) provided on August 18, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for pathology services. You say that the doctor's office failed to send in a preauthorization form for approval. The Plan denied your request. The Plan says you are not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility.  

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 pathology services (88312, 88305) provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on February 21 to April 24, 2020.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for psychotherapy services was not filed until June 3, 2021. This means that more than one calendar year from the dates of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on February 21 to April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99202, 99204) manual electrical stimulation (97032) radiologic examination of the entire spine (72010) infrared light therapy (97026) magnetic resonance therapy (97039) therapeutic procedure, neuromuscular re-education (97112) provided July 26, 2021 to July 29, 2021.  You asked the Plan to pay for the chiropractic services. You say that these are medically necessary treatments and they need to be covered. The Plan denied your request. The Plan says maintenance chiropractic therapy that does not meet Medicare criteria is not covered.  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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202, 99204) manual electrical stimulation (97032) radiologic examination of the entire spine (72010) infrared light therapy (97026) magnetic resonance therapy (97039) therapeutic procedure, neuromuscular re-education (97112) provided July 26, 2021 to July 29, 2021.