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

 We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on February 4, 2021.  

You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you hit your maximum out-of-pocket (MOOP) and should not have to pay the coinsurance. The Plan denied your request. The Plan says the claim was adjusted which adjusted the enrollees MOOP. The coinsurance applied for this service hit the enrollees MOOP.   

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 Part B drugs, including chemotherapy drugs. The total amount allowed was $2,251.51. A 20% coinsurance amount would be $450.30 ($2,251.51 total amount x 20% coinsurance) which is greater than the charged amount of $300.91 for coinsurance. The MOOP was hit with the $300.91. Therefore, the coinsurance amount of $300.91 was charged.   

You have been asked to pay a 20% coinsurance for the chemotherapy drugs. The chemotherapy drugs 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 chemotherapy drugs provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for water chamber (A07046), headgear (A7035), full mace mask (A7030), tubing with heating (A4604), and face mask interface (A7031), provided on August 3, 2021.  You asked the Plan to waive the copayment for the continuous positive airway pressure accessories. You say that the items should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 35% copayment for durable medical equipment (DME) and relates supplies.   You have been asked to pay a 35% copayment for the continuous positive airway pressure accessories. These items fall within the durable medical equipment (DME) and relates 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 copayment for water chamber (A07046), headgear (A7035), full mace mask (A7030), tubing with heating (A4604), and face mask interface (A7031), provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the selective catheter placement billed with the -59 modifier (36215-59) and angiography (75710) provided on June 8, 2021.  

You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed in accordance with Medicare coding regulations.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  

In this case, the CPT Code Manual definition of code 36215-59 is Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family. The CPT Code Manual definition of code 75710 is Angiography, extremity, unilateral, radiological supervision and interpretation.  

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 medical services. Our reviewer says that the documentation does not support the claim as billed. Our reviewer found that the medical records provided do not include sufficient documentation to validate that 36215-59 was performed as a distinct/separate service; therefore, this procedure is not eligible for separate reimbursement and is included in payment for 36902 performed on June 18, 2021 during the same operative session. Furthermore, the medical records provided does not include sufficient documentation to validate that an Angiography, extremity, unilateral, radiological supervision and interpretation was performed on June18, 2021, therefore this procedure cannot be verified.   

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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement billed with the -59 modifier (36215-59) and angiography (75710) provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 surgical placements of an implant body: endosteal implants (D6010 x10).  You asked the Plan to pre-approve the endosteal implants. You say that you cannot chew because you have no back molars. You also say that you have no money to pay for implants. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 10 surgical placements of an implant body: endosteal implants (D6010 x10).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910), periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), and intraoral - periapical first radiographic image (D0220) provided August 19, 2021, and November 19, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the periodontal maintenance, periodic oral exam, bitewing x-rays and intraoral x-ray. You say that this provider was in-network under your previous insurance. The Plan denied your request. The Plan says these services are not covered when provided OON.  

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 covers the periodontal maintenance, periodic oral exam, bitewing x-rays and intraoral x-ray when the services are provided by an in-network dentist.  

We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the periodontal maintenance, periodic oral exam, bitewing x-rays and intraoral x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274), and intraoral - periapical first radiographic image (D0220) provided August 19, 2021, and November 19, 2021, by an out-of-network (OON) provider.   

Your complaint about potentially being provided incomplete or incorrect information about the network status of this dentist 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.

You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says Xiidra is a self-administered
drug and does not fall under Part B coverage.

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 pre-approve Xiidra.

Benefits for Xiidra 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve physical therapy services to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says generally members must receive care from a network provider. In most cases, care the member receives from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The member's Evidence of Coverage states care will be directed outside of the primary network only if it has been determined that they cannot provide the necessary care to the member.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
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 the enrollee cannot be adequately managed in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the LTACH would add no additional services.  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 physician reviewer found that the enrollee was admitted to the acute care hospital with persistent respiratory distress, hypoxia, septic shock, and pneumonia. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).  You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported crown. You say that the original dentist pulled your tooth and another dentist told you that the tooth should never have been pulled. The Plan denied your request. The Plan says these services are not covered under your benefit package.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).  You asked the Plan to pre-approve a complete upper denture. You say that you broke your dentures and need new ones. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete upper denture once every five plan years.      We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper denture was previously covered on September 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
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. The Plan denied your request. The Plan says the enrollee's needs can be met on an intermittent basis.  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 physician reviewer found that you were admitted to the acute care hospital for congestive heart failure. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on August 26, 2021.  You asked the Plan to pay for the hospital outpatient clinic visit. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services cannot be paid based on the billed diagnosis.  The Plan must follow Medicare rules. Medicare rules say that Services or devices directed toward the care or correction of "flat foot" are not covered.  We looked at the file and Medicare rules. In this case, the billed diagnosis is flat foot which is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the hospital outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) provided on August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 9, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 9, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from February 9, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 9, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 9, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from February 9, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 9, 2022, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from August 30, 2020, through September 1, 2020, and billed with the principal diagnosis code A41.9.  You asked the Plan to pay for the inpatient hospital care. You say that this hospital care has been billed appropriately with an accurate principal diagnosis code. The Plan denied your request. The Plan says the documentation does not support the services as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, unspecified organism. 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 a principal diagnosis of A41.9 defined as Sepsis, unspecified organism. Our physician reviewer found that the review indicates that the documentation supported an admission for pneumonia. The documentation was unclear regarding a diagnosis of sepsis. Even though sepsis is throughout the medical record, supporting documentation was not found. The enrollee was a then, 74-year-old male who presented with complaints of chest pain, fever, and cough. The patient was admitted for sepsis and pneumonia. The patient's fever quickly trended down with treatment in the emergency room. There is no documentation of persistent hypotension or hemodynamic instability. The patient was discharged within 48 hours of admission. The review has determined that the documentation did not support the billing of principal diagnosis code A41.9 defined as sepsis, unspecified organism.   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 30, 2020, through September 1, 2020, and billed with the principal diagnosis code A41.9.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dupixent injection.  You asked the Plan to pre-approve Dupixent. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 pre-approve Dupixent injection.   Benefits for Dupixent 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 modification of removable prosthesis following implant surgery (D5875), add metal substructure to acrylic full denture (D5876), two surgical placements of an implant body: endosteal implant (D6010 x2), mandibular implant/abutment supported removable denture for edentulous arch (D6111), and radiographic/surgical implant index (D6190).  

You asked the Plan to pre-approve the modification of removable prosthesis, add metal substructure to acrylic full denture, endosteal implants, mandibular implant/abutment supported removable denture, and radiographic/surgical implant index. You say that you cannot afford to pay for the implants yourself. You also say that you cannot use regular dentures because your bone structure will not support the dentures. The Plan denied your request. The Plan says these services are not covered under your benefit package.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a modification of removable prosthesis following implant surgery (D5875), add metal substructure to acrylic full denture (D5876), two surgical placements of an implant body: endosteal implant (D6010 x2), mandibular implant/abutment supported removable denture for edentulous arch (D6111), and radiographic/surgical implant index (D6190).