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

 We decided that the Plan does not have to pay for continuation of SNF services provided from April 17, 2021, through April 23, 2021.  You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the SNF services provided from April 17, 2021, through April 23, 2021, were not medically necessary.  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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to provide medically necessary and reasonable treatment safely and effectively from April 17, 2021, through April 23, 2021. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment provided from April 17, 2021, through April 23, 2021. No skilled services were required from April 17, 2021, through April 23, 2021. As a practical matter, this enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from April 17, 2021, through April 23, 2021.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from April 17, 2021, through April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on October 20, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  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 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 out of network medical services provided to the enrollee on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special anesthesia service rendered on May 10, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99100 is not supported.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99100 (anesthesia for patient of extreme age, younger than 1 year and older than 70 [List separately in addition to code for primary anesthesia procedure]) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia service rendered on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on May 25, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network medical services provided to the enrollee on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the visit you had with a neurosurgeon on June 29, 2021.  You asked the Plan to waive the copayment for the neurosurgery visit. You say that you saw your doctor and then a Physician's Assistant. You said that you were not aware that the physician's assistant was not in the plan's network, so this should be covered. The Plan denied your request. The Plan says it has reprocessed the claim for the Physician's Assistant services and you have no liability for those. You are only being charged an office visit copayment for the visit with your neurosurgeon. The Plan says that this copayment was charged 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 $45 copayment for visits with a specialist.  You have been asked to pay a $45 copayment for the neurosurgery visit. The neurosurgery visit falls within the visits with 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 visit you had with a neurosurgeon on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (01638, 64415) provided on January 5, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not 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, the CPT Code Manual definition of code 01638 is "Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total shoulder replacement".  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 01638 is not supported by the records provided. Our reviewer found that the documentation did not include a detailed anesthesia report to support this procedure, and therefore it cannot be verified. The documentation submitted includes a surgical report without mention of anesthesia services.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.  In this case, we have also confirmed that code 64415 is a column II code to column I code 01638. 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 services (01638, 64415) provided on January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 6, 2020, to May 12, 2020.   You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted in this case.  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.    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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the documentation supported an admission for pneumonia. The documentation was unclear regarding  a diagnosis of sepsis and respiratory failure. Even though sepsis and acute on chronic respiratory failure are documented as diagnoses throughout the medical record, supporting documentation was not found. The review has determined that the records did not support that the correct DRG and diagnosis codes were used in this case.   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 inpatient hospital services provided to the enrollee from May 6, 2020, to May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fillings for tooth #20 and #21 provided on July 28, 2021.  You asked the Plan to pay for the fillings. You say that the latest surface bonding peeled off, so you let your dentist fix it. You say that you didn't realize there were frequency limitations, and the denial should be waived. The Plan denied your request. The Plan says fillings are only covered once every 24 months.  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, you also have a maximum benefit of one filling per tooth every 24 months. The Plan paid for the filling for tooth #20 and #21 provided on July 13, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the fillings for tooth #20 and #21 provided on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on May 19, 2021.  You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that this should not be considered a surgery. You said that this was simply the drainage of a cyst. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for outpatient procedures and services in an outpatient hospital facility.      You have been asked to pay a $350 copayment for the arthrocentesis procedure. The arthrocentesis procedure falls within the outpatient procedures and services in an outpatient hospital facility 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 arthrocentesis procedure you had at an outpatient hospital facility on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a methylprednisolone sodium succinate injection (J2920) and a Ferumoxytol injection (Q0138) rendered on July 6, 2021.  You asked the Plan to waive the coinsurance for a methylprednisolone sodium succinate injection and a Ferumoxytol injection. You say that this is what you would pay without the Plan's insurance since Medicare covers 80%. You also say that the Plan should cover the 20% leftover after Medicare pays its share. The Plan denied your request. The Plan says you were 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 20% coinsurance for in-network, Medicare Part B Drugs.    You have been asked to pay a $97.71 coinsurance, which is 20% of the allowed amount for a methylprednisolone sodium succinate injection and a Ferumoxytol injection ($488.53 allowed amount x 20% coinsurance = $97.71). Methylprednisolone sodium succinate injections and Ferumoxytol injections fall within the Medicare Part B 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 a methylprednisolone sodium succinate injection (J2920) and a Ferumoxytol injection (Q0138) rendered on July 6, 2021.   Your complaint about what the Plan potentially covers and does not cover 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the 3-D rendering with interpretation provided on June 18, 2021.  You asked the Plan to waive the copayment for the 3-D rendering service. You say that you don't think you should have to pay a separate copayment for the service to get a clear picture from the computed tomography (CT) scan. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($63.63) is less than your copayment, you are responsible for the full allowed 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 $110 copayment for radiological diagnostic services.   You have been asked to pay a $110 copayment for the 3-D rendering service. The 3-D rendering is a separate and distinct service from the CT scan you had, so separate cost sharing can apply. The 3-D rendering service falls within the radiological diagnostic 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 3-D rendering with interpretation provided on June 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on May 24, 2021.  You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is 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 70450 is a column II code to column I code 70496. 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 a computed tomography scan (70450) provided on May 24, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, (99291) provided on January 31, 2021.  You asked the Plan to pay for the critical care service. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on January 25, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, (99291) provided on January 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the lumbar spine rendered on April 30, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.   We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the computed tomography (CT) scan of the lumbar spine rendered on April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from June 1, 2021, to June 30, 2021.  You asked the Plan to waive the copayment for the SNF services. You say that you were under the impression that these services were covered by your insurance. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that you only had $1879.36 remaining on your out-of-pocket maximum, so you are only being charged that amount instead of the full copayment owed for the SNF services.  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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-41 for skilled nursing facility services.   Records show that you were admitted to the SNF on May 30, 2021, and discharged on July 1, 2021, for a total of 32 days.  You were not charged a copayment for the first 20 days.  For the remaining 12 days, you were charged a copayment of $184 per day, for a total of $2208.  However, as the Plan noted above, you only had $1879.36 remaining on your out-of-pocket maximum for the year, so that is what you are being charged. 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 skilled nursing facility (SNF) services you received from June 1, 2021, to June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional (93293) rendered by the out-of-network (OON) provider on July 21, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional (93293) rendered by the out-of-network (OON) provider on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression wraps.  You asked the Plan to pre-approve compression wraps. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that a gradient compression wrap is only covered when it is used as a primary or secondary dressing over wounds that meet the statutory requirements for a qualifying wound.  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 compression wraps. Our reviewer says that the items are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Determination (LCD): Surgical Dressings - L33831. Records do not document that the Farrow wraps will be used as a primary or secondary dressing over wounds that meet the statutory requirements for a qualifying wound (surgically created or modified, or debrided).  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of compression wraps have not been met. Therefore, we decided that the Plan does not have to pre-approve compression wraps.