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

 We decided that the Plan does not have to waive the coinsurance for the drug injection you received on November 24, 2020.  You asked the Plan to waive the coinsurance for the drug injection. You say that you were never told about any cost sharing and you cannot afford this bill. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs and administration.   You have been asked to pay 20% coinsurance for the drug injection. The drug injection falls within the Medicare Part B drugs and administration 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 coinsurance for the drug injection you received on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and complete series of x-rays (D0210) provided on November 1, 2021.  You asked the Plan to pay for the comprehensive exam and x-rays. You say that you confirmed with your provider that you would only receive services that would be covered, and this cost is a financial burden. The Plan denied your request. The Plan says that you previously had these services in March 2021, and you have exceeded the frequency limitations of your benefit.  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 can cover one periodontal exam or one comprehensive oral evaluation every three years. The Plan can also cover one complete series of x-rays or one panoramic x-ray every five years.  We looked at the file and the Plan's rules. The Plan argues that you have already had these services and has forward the information for the claim cited in their denial. The Plan states that you previously had these services provided on March 25, 2021. The claim for that date does not show that you had either a comprehensive oral evaluation or a periodontal oral evaluation. The claim also does not show that you had either a panoramic x-ray or a complete series of x-rays provided on the date in question. The Plan has not provided any other information to show that you have exceeded the frequency limitation of your benefit, and the Plan's argument is not supported in the documentation. Based on this information, we decided that the Plan's rules for coverage of the comprehensive exam and x-rays have been met. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and complete series of x-rays (D0210) provided on November 1, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on August 20, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says there are no benefits 
for hearing aids from an out of network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids when provided from any network hearing or hearing aid provider.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided from the 
Plan's network hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids 
provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had at an outpatient hospital facility on September 30, 2021.  You asked the Plan to waive the coinsurance for the outpatient surgery. You say that had you known about the cost, you would have taken a different approach.  You said that you were misled about the cost of this procedure. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for surgery performed in an outpatient hospital facility.   You have been asked to pay 20% coinsurance for the outpatient surgery. You had this procedure at an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had at an outpatient hospital facility on September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88120) provided on July 14, 2021.  You asked the Plan to pay for the laboratory services (88120). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  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 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 the laboratory services (88120) provided on July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme (Q0138).  You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Infed (iron dextran) and Venofer (iron sucrose).  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Feraheme. Our reviewer says that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the preferred drugs, Infed (iron dextran) and Venofer (iron sucrose). The reviewer also found that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects 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 Feraheme have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0138).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from August 31, 2020, through September 2, 2020, billed with the diagnosis code N17.9.  You asked the Plan to pay for the inpatient hospital care. You say that the diagnosis code billed is supported by the medical documentation. The Plan denied your request. The Plan says the claim has not been billed correctly based on the medical records that have been provided.   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 the diagnosis code, N17.9, defined as acute kidney injury. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that the documentation does not support the billed diagnosis N17.9, defined as acute kidney injury. Our physician reviewer found that the reviewed documentation indicates that the patient was a then, 77-year-old male who was admitted on August 31, 2020, with complaints of weakness and being very thirsty. The patient's health history included diabetes. There was no documentation of anuria or decreased urine output. The patient was discharged to home with home health on September 2, 2020. Discharge diagnosis included diabetic ketoacidosis, dehydration, acute renal failure, pseudohyponatremia, hypercalcemia, and abnormal urinalysis. The documentation does not support the diagnosis of acute kidney injury. The review has determined that the documentation did not support the inpatient care billed with the diagnosis of N17.9 defined as acute kidney injury.   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 hospital care provided from August 31, 2020, through September 2, 2020, billed with the diagnosis code N17.9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facility evaluation and management visits provided on 
November 3, 2021.
You asked the Plan to pay for facility evaluation and management visits. The Plan denied your request. 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 Plan says that the Plan has also determined that these 
services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 facility evaluation and management visits provided on 
November 3, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided July 22, 2021.
You asked the Plan to pay for a pneumatic compression device and appliance. You say that it is your 
understanding that this claim was denied the care was experimental/investigational. The explanation of benefits 
did not give adequate information to establish the accuracy of this decision. The Plan denied your request. The 
Plan says the benefit for this service is included in the payment/allowance for another service/procedure that 
has already been adjudicated. This service cannot be billed separately.
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. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance 
(E0673) provided July 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the femoral nerve anesthesia injection (64447) provided on July 21, 2021.  You asked the Plan to pay for the femoral nerve anesthesia injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that an edit exists between CPT codes 64447 and 01402.  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 64447 is injection(s), anesthetic agent(s) and/or steroid; femoral nerve  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 femoral nerve anesthesia injection. Our reviewer says that CPT code 64447 meets criteria for billing and reimbursement consideration. Our reviewer found the procedure report documents anesthesia injection for post operative pain, and therefore would be covered, for same date of service as general anesthesia reported.  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 femoral nerve anesthesia injection have been met. Therefore, we decided that the Plan has to pay for the femoral nerve anesthesia injection (64447) provided on July 21, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a retacrit (for non-ESRD use) injection (Q5106) provided on 
August 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a retacrit (for non-ESRD use) injection. You say that you are requesting an 
appeal as this enrollee meets all criteria per Plan policy. The Plan denied your request. The Plan says this 
provider is a non-network provider who does not work with the Member's Plan, and the member was also 
referred by a non-participating provider. The Plan also says that the member's primary care physician did not 
refer for services and no medical necessity for an out-of-network provider, such as an urgent or emergency 
situation has been documented.
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 a retacrit (for non-ESRD use) injection (Q5106) 
provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (85025) provided on August 23, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that this claim is being denied for the referring
provider. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and
the services were not referred by a network provider or rendered in an in-network facility. The Plan also says
that they have also determined that these services are not urgent or emergent, nor were they approved in
advance.
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 laboratory services (85025) provided on August
23, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a lumbar orthosis (back brace) provided 
on August 31, 2021.
You asked the Plan to waive the coinsurance for the back brace. You say that you tried to return the brace but 
the provider would not accept it. 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 a 20% 
coinsurance for prosthetic devices, supplies related to prosthetic devices, and orthotics.
You have been asked to pay $49.30, which is 20% of the allowed amount for the back brace ($246.49 allowed 
amount x 20% coinsurance = $49.30). The back brace falls within the Prosthetic Devices and Related Supplies 
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 coinsurance for a lumbar orthosis (back brace) 
provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a ROMTech Portable Connect Adaptive Rehabilitation Device.  You asked the Plan to pre-approve these services. You say that the item is necessary and not exercise equipment. The Plan denied your request. The Plan says the services are not covered.    The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a ROMTech Portable Connect Adaptive Rehabilitation Device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and sales tax (D9985) provided on
September 22, 2021.
You asked the Plan to pay for the consultation and sales tax. You say that these services were provided on an
emergency basis. You also say that there was no time to take out a supplemental dental policy. The Plan denied
your request. The Plan says you did not have active dental coverage with this plan when these services were
rendered.
Medicare generally does not cover dental services. The Plan follows the same rule. The rules also say that
Medicare does not make separate payment for sales tax.
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 consultation (D9310) and
sales tax (D9985) provided on September 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for psychotherapy administered in a group setting (90853) provided June 9, 2021.  You asked the Plan to pay for the psychotherapy services. You say that please reconsider the payment on this claim. The Plan denied your request. The Plan says that the service is not supported without required documentation.  The Plan must follow Medicare rules. The rules say that If consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. This does not apply if the physician referred the patient to the CP.  We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for psychotherapy administered in a group setting (90853) provided June 9, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 18, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in an Off Campus-Outpatient Hospital POS 19. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 18, 2021.