Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composites (D2330, D2391, D2392, and D2393) provided on September 27, 2021.  You asked the Plan to pay for the resin-based composites. You say that you would have bought the enhanced dental coverage if you had known about it. The Plan denied your request. The Plan says these services are not covered benefits under the dental plan. The Plan also says that you did not enroll in or purchase the enhanced dental and vision package.  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 resin-based composites (D2330, D2391, D2392, and D2393) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services coded with DRG 291 provided July 16, 2020 to July 21, 2020.  You asked the Plan to pay for the inpatient services coded with DRG 291. 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 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 Secondary diagnosis of J96.01, defined as acute respiratory failure with hypoxia. 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 coded with DRG 291. Our reviewer says that the documentation does not support the DRG 291 billing. Our physician reviewer found the enrollee presented to an acute hospital with chief complaints of bilateral leg swelling, rapid heart rate and generalized weakness. The enrollee was admitted to the hospital with a primary diagnosis of hypertensive heart disease with heart failure. Despite rales on examination at times and imaging reporting pulmonary edema and pleural effusion and treatment with diuresis with furosemide, other history and examination notes report no respiratory distress and normal breath sounds, no hypoxia with oxygen saturation below 91% was documented during the hospitalization; no supplemental oxygen or mechanical ventilation was utilized during the hospital stay. The secondary diagnosis code assignment of J96.01, acute respiratory failure with hypoxia is not supported by the documentation.   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 the inpatient services coded with DRG 291 provided July 16, 2020 to July 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from June 3, 2021, to June 6, 2021.  You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require daily skilled therapy services on an inpatient basis.  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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 3, 2021, to June 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for a medical eye exam (92014) provided on October 1, 2021.  You asked the Plan to reduce the copayment for a medical eye exam. You say that you had a routine eye exam and you believe this should be covered in full. The Plan denied your request. The Plan says the copayment you are being charged is correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.  You have been asked to pay a $45 copayment for a medical eye exam. The records show that you had a one-year follow-up visit for cataracts in both eyes. The EOC confirms that $45 is the required copayment for this service. A medical eye exam falls within the vision 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 reduce the copayment for a medical eye exam (92014) provided on October 1, 2021.
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 from September 15, 2020, through October 12, 2020.  

You asked the Plan to waive the copayment for the SNF care. You say that the service should be covered. 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 $100 copay per day 21-100; the first 20 days are covered for skilled nursing facility (SNF) care.     

You have been asked to pay a $100 copay per day 21-100; the first 20 days are covered for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. The records indicates the member was in a SNF for 27 days, the Plan covered the first 20 days, and the enrollee is responsible for a copay for each of the 7 remaining days. 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 from September 15, 2020, through October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065), provided on September 2, 2021.  You asked the Plan to pay for the implant supported crown. You say that the Plan should cover 25% of this service. The Plan denied your request. The Plan says this is not a covered 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.      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. Specifically, the supplemental plan you enrolled in does not cover implant services. Because the requested service is an implant supported crown, it is not covered. Therefore, we decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065), provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on July 1, 2021.  You asked the Plan to pay for dental services. You say that the provider opted out of Medicare as his services are not typically covered by Medicare, however, the provider has not opted out with the Plan. You are asking for a reconsideration of payment. The Plan denied your request. The Plan says the requested provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. We have confirmed that the provider opted out of Medicare on December 1, 2020. This means the provider was opted out of Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the closure of tear duct (68761) provided on July 8, 2021.  You asked the Plan to pay for the closure of tear duct (68761). You say that modifier 24 was used to indicate this was not related to the cataract surgery. You say that the patient had dry eye before surgery, continues to have it afterward and this is what was treated during the visit. The Plan denied your request. The Plan says this procedure is included within the global surgery package of procedure 66984 billed on June 8, 2021.  The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the closure of tear duct (68761) have not been met. Specifically, the record indicates that the member had cataract removal surgery (66984) on June 8, 2021. CPT code 66984 has a global surgery period of 90 days. This service was rendered within the 90-day surgical period and an appropriate modifier was not appended to indicate that this was an unrelated service. Therefore, we decided that the Plan does not have to pay for the closure of tear duct (68761) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a bladder cancer screening (88120) provided on March 8, 2021.  You asked the Plan to pay for a bladder cancer screening. You say that this is supported in the records. The Plan denied your request. The Plan says this was a screening service.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a bladder cancer screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a bladder cancer screening (88120) provided on March 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.  

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for inpatient admission.  

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   

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 hospital services. Our reviewer says that that inpatient hospital services are not medically reasonable and necessary for the enrollee.  The patient presented to the emergency department due to altered mental status, low grade fever, cough, sore throat and decreased appetite. The enrollee's labs were improving at the time of admission. Observation level of care was more appropriate. Based on improvement at the time of admission, it was not expected that the patient would require hospital services that would likely cross 2 midnights at the time of admission. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services.  

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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy provided on October 11, 2021.  You asked the Plan to waive the copayment for the physical therapy. You say that you should not have to pay a copay. 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 $35 copay for outpatient rehabilitation services.   You have been asked to pay a $35 copay for the physical therapy. This service falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy provided on October 11, 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 this is medically necessary. The Plan denied your request. The Plan says the care could be received in another 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 admitted for respiratory failure, coronavirus (COVID) pneumonia, and congestive heart failure. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Partially Favorable

 We decided that the Plan has to pay for the services provided. We decided that the Plan does not have to pay for monitoring services identified by code 95908 provided on March 11, 2021.   You asked the Plan to pay for the services provided. You say that all procedure codes are necessary to get a complete picture of the nervous system. The Plan says that there are no modifiers allowed with this code pair.  We decided that the Plan has to pay for the monitoring services identified by codes G0453, 95929, and 95938.   The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  We looked at the file and the rules. The Plan has not sent us anything substantial to indicate that the remaining codes are not appealable. The Plan has also not sent us any substantial evidence to show why those services were denied in the first place. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the monitoring services identified by codes G0453, 95929, and 95938 on March 11, 2021.   We also decided that the Plan does not have to pay for monitoring services identified by code 95908.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 95908 was billed along with code 95861. We find that code 95908 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Therefore, we decided that the Plan does not have to pay for monitoring services identified by code 95908 provided on March 11, 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on February 4, 2021.  You asked the Plan to pay for the therapy services and vitamin injections. The Plan denied your request. The Plan says the Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit.   The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The Rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services and vitamin injections have not been met. Specifically, we find that the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy.   In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the therapy services and vitamin injections provided on February 4, 2021.