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

We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter (A4221), Treprostinil (J3285) and infusion pump (K0455) provided on July 14, 2019, through August 12, 2019.

You asked the Plan to pay for the infusion catheter supplies, Treprostinil and infusion pump. You say that you would like reconsideration because these supplies were medically necessary. The Plan denied your request. The Plan says the proof of delivery that was submitted is incomplete. 

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery. Specifically, the Prescriber Signature and Signature Date lines are blank, the date of delivery is not specified and there is no enrollee signature to verify that the equipment was delivered and received. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter (A4221), Treprostinil (J3285) and infusion pump (K0455) provided on July 14, 2019, through August 12, 2019.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria. 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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the services you require are custodial.  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 services. Our physician reviewer found that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on October 11, 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 services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on January 26, 2021.  

You asked the Plan to reimburse you for the hearing aids. You say that you received letters from the Plan stating that your Plan covers hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider. The hearing benefit is not covered if the services are not registered in advance.  

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 only when received from the Plan's hearing network provider.        

We looked at the file and the Plan's rules. The file shows that the hearing aids were not received from the Plan's hearing network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter (A4221), Treprostinil (J3285) and infusion pump (K0455) provided on September 12, 2019, through October 11, 2019.  You asked the Plan to pay for the infusion catheter supplies, Treprostinil and infusion pump. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid Proof of Delivery.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion catheter (A4221), Treprostinil (J3285) and infusion pump (K0455) provided on September 12, 2019, through October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Axumin positron emission tomography (PET) scan for the enrollee.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this request is not supported for the first staging (finding extent of disease) of prostate cancer.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found per the package insert, an Axumin scan is indicated for suspected prostate cancer recurrence following prior treatment. As treatment has not happened yet, the criteria are not met.       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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Axumin positron emission tomography (PET) scan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for podiatry visits you had on September 3, 2021, and September 24, 2021.  You asked the Plan to waive the copayment for the podiatry visits. You say that you are on a limited income and cannot pay this bill. The Plan denied your request. The Plan says these copayments were charged correctly.  The Plan says that it has waived the coinsurance charged for the walking boot, so you are only responsible for the two copayments for these office visits.  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 $5 copayment for visits with a podiatrist.    You have been asked to pay a $5 copayment for the podiatry visits. 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 podiatry visits you had on September 3, 2021, and September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services and a specialist office visit provided on November 30, 2021.  You asked the Plan to waive the copayment for the laboratory services and specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Outpatient diagnostic tests and therapeutic services and supplies and a $35 copayment Physician/Practitioner services, including doctor's office visits.    You have been asked to pay a $3.48 copayment for the laboratory services, which is less than the $10 stated in the Plan's contract and a $35 copayment for a specialist office visit. Laboratory services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category and specialist office visits fall within Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services and a specialist office visit provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  November 9, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the full routine vision hardware allowance of $220 was applied to this claim.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan has paid the full routine vision hardware allowance of $220. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient surgery you had at an ambulatory surgical center on October 27, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that you cannot afford this bill. 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 $250 copayment for outpatient surgery.      You have been asked to pay a $250 copayment for the outpatient surgery. 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 outpatient surgery you had at an ambulatory surgical center on October 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 29874 billed for date of service April 22, 2021.  

You asked the Plan to pay for procedure code 29874. You say that you have provided medical records to support payment. The Plan denied your request. The Plan says payment for this code is bundled into payment for 29880.  

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 procedure code 29874 is a column II code to column I code 29880. According to these NCCI edits, this code is always bundled, and modifiers should not be submitted for an exception. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 29874 billed for date of service April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (body jacket brace) provided on September 22, 2021.  You asked the Plan to waive the coinsurance for the back brace. You say that the provider informed you that the brace would be covered. 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 durable medical equipment (DME), including back braces.   The file shows that the brace was a covered item, but coinsurance still applies. Therefore, you have been asked to pay $149.66, which is 20% of the allowed amount for the back brace ($748.30 allowed amount x 20% coinsurance = $149.66).  The back brace falls within the Durable Medical Equipment (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 a lumbar-sacral orthosis (body jacket brace) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical extractions (D7210) provided on October 28, 2021.  You asked the Plan to pay for surgical extractions. You say that your insurance says that oral surgery is covered, and this service was necessary. The Plan denied your request. The Plan says this type of extraction is not covered by your dental benefit. The Plan also confirmed with your provider that the extraction provided in this case was surgical.  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's contract states that oral/maxillofacial surgery and surgical extractions are not covered.  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 surgical extractions (D7210) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on August 31, 2021.  You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you must go through the Plan's hearing aid provider for coverage of the benefit.  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 only when you go through the Plan's hearing aid provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on September 20, 2021.   You asked the Plan to pay for the self-administered drugs. You say that you were treated in the emergency department. You also say that you would like these items to be covered. The Plan denied your request. The Plan says the drugs you received considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on September 20, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a treatment of root canal obstruction (D3331) to be provided by an endodontist.  You asked the Plan to pre-approve the treatment of root canal obstruction. You say that you are experiencing a lot of pain and were referred to an endodontist. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an endodontist are not covered.  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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a treatment of root canal obstruction (D3331) to be provided by an endodontist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19 complicated by cerebral hemorrhages and renal failure. The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube. The enrollee is undergoing ventilator weaning.  There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for psychotherapy services provided from June 10, 2019, to August 26, 2019.  You asked the Plan to waive the copayments for the psychotherapy services. You say that you feel that the enrollee should not be responsible for the copayments due to untimely billing. The Plan denied your request. The Plan says the enrollee has been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $15 copayment for each individual or group therapy visit.   The enrollee has been asked to pay a $15 copayment for each visit for the psychotherapy services. The file shows 9 visits from June 10, 2019, to August 26, 2019, for a total responsibility of $135 ($15 copayment x 9 visits = $135). The psychotherapy services fall within the Outpatient Mental Health Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for psychotherapy services provided from June 10, 2019, to August 26, 2019.