Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided August 14, 2021, to August 20, 2021.  

You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that the services were medically necessary. 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 $1,650 copayment per admission for each inpatient stay.  

You have been asked to pay a $1,650 copayment for the inpatient hospital admission and services. The inpatient hospital admission and services falls within the Inpatient hospital 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 inpatient hospital admission and services provided August 14, 2021, to August 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services provided from August 25, 2021, to August 29, 2021
.  
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
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 looked at the file and the rules. We find that CPT code S9500 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. 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 home infusion therapy services provided from August 25, 2021, to August 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on July 20, 2021.  You asked the Plan to pay for eye refraction. You say that you had cataract surgery so this exam was needed to determine your new prescription for eyeglasses. The Plan denied your request. The Plan says the denial of payment for this service is correct, because Medicare does not cover routine eye exams such as refractions.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.   The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve aquatic therapy.  

You asked the Plan to pre-approve aquatic therapy. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says you do not meet coverage criteria for the service at issue.  

The Plan follows Medicare rules. Medicare rules say that aquatic therapy with therapeutic exercise may be considered medically necessary if at least one of the conditions listed in the Medicare rules section of this letter is present and documented.  

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 aquatic therapy. Our reviewer says that criteria for the services at issue have not been met. Our physician reviewer found that the documentation does not reveal that you meet the coverage rules for the aquatic therapy. The services at issue are not medically necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on August 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that the treatment was medically necessary. The Plan denied your request. The Plan says the services were not authorized. 

 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 office visit provided on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).  

You asked the Plan to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional methods. You say that the member has tried and failed conservative treatments without relief, and the procedure is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy.  

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 spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine surgery (22899) and destruction of intraosseous basivertebral nerve (C9752 and C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement of a loop recorder for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is asymptomatic and no documentation of unexplained syncope or cyprtogenic stroke.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee has a history of successful catheter ablation of atrial fibrillation in 2015, without recurrences. She is asymptomatic. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement of a loop recorder for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on October 21, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that according to your 2022 Annual Notice of Change, its indicated that non-Medicare preventative dental services, as provided under the optional supplemental benefits, are covered at $0 copay. You also say that the document states with both in and out of network providers. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that out of network providers may bill you for any amount greater than what the plan paid.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, out of network dentists may bill you for any amount greater than what the plan pays. The record shows that the Plan paid the allowed amount for the services you received. The Evidence of Coverage clearly states that you will be responsible for the full amount by which the actual charges of an out of network dentist exceed the allowable charge. Therefore, we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia services (99100) provided on March 8, 2021.  

You asked the Plan to pay for special anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not a separately payable code.  

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  

We looked at the file and Medicare rules. Code 99100 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services (99100) provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME provided on April 2, 2021.
  
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you never took the equipment home and left it at the outpatient rehabilitation facility for the provider to pickup. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for DME and related supplies.
   
You received DME on April 2, 2021. The total allowed amount is $110 and 20% of that is $22.  

You have been asked to pay the total coinsurance amount of $22 for DME. DME falls within the DME 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 DME provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit coded 99214 provided on December 29, 2020.  You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that code 99214 is a column II code to column I code 96372. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 provided on December 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on May 12, 2021.
  
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you've never had to pay for your injections before. You say that you cannot afford this and want it to be covered. The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs. 
   
You have been asked to pay $878.36, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $4,391.80 (20% x $4,391.80 = $878.36). The denosumab injection falls within the "Medicare Part B prescription drugs" 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 denosumab injection provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power wheelchair accessories to be provided by an out-of-network (OON) provider.
  
You asked the Plan to pre-approve the power wheelchair accessories. You say that you are an in-network provider. The Plan denied your request. The Plan says the provider is out-of-network.
  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair accessories to be provided by an out-of-network (OON) provider.
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 is medically necessary for your condition. The Plan denied your request. The Plan says rules for IRF care have not been met.  

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 that you were admitted for surgical repair of a femur fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. 

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care provided after December 1, 2021.  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 at the time of admission, you required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of December 1, 2021, you did not require any skilled nursing or rehab services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. You did not require skilled therapy to establish a safe and effective maintenance program. Your function was at or near her prior level of function and she could be discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care provided after December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021.  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 billed are not separately payable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on August 13, 2020.  

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the claim was received past the allowed 12-month timeframe.  

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 physician's services was not filed until August 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an Annual Wellness Visit provided on October 4, 2021.  

You asked the Plan to pay for Annual Wellness Visit. You say that your Annual Wellness Visit was screwed up by coding and you should not be responsible for this mistake. The Plan denied your request. The Plan says the denial of payment for this service is correct, because you previously received an Annual Wellness Visit on June 1, 2021 so this benefit was exhausted.  

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for an Annual Wellness Visit provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 14, 2021.
  
You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes are included           
in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis center.
  
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable
.   
We looked at the file and the rules. The records show that the labs were provided as part of the enrollee's ESRD treatment.   
Labs should bill the facility directly for lab services as they are considered part of the composite rate
.  
No other payment for these services is allowed. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit received by a chiropractor on September 10, 2021.  

You asked the Plan to pay for the office visit. You say that the office visit was for a chiropractic adjustment to your lower back area. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by a chiropractor. 

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 office visit received by a chiropractor on September 10, 2021.