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

 We decided that the Plan does not have to pay for the emergency ambulance transport (A0429) and ground mileage (A0425) provided on May 24, 2021.  You asked the Plan to pay for the emergency ambulance transport and ground mileage. The Plan denied your request. The Plan says certain ambulance services need to be reported with a diagnosis to indicate the medical condition of the patient is such that transportation by any other means is medically contraindicated.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.    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 emergency ambulance transport and ground mileage. Our reviewer says that the documentation does not show that the ambulance transport on May 24, 2021 met Medicare criteria for medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee's presenting symptoms of general weakness and not feeling well met a prudent layperson's criteria for emergency care. All of his reported vital signs and physical assessment data showed nothing that appeared to require emergency care. Our reviewer found that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were not contraindicated for this enrollee. Our physician reviewer also found that the enrollee did not need the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on May 24, 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 the emergency ambulance transport and ground mileage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency ambulance transport (A0429) and ground mileage (A0425) provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676).  You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this device is not covered according to Medicare rules.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.   We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 26, 2021.  You asked the Plan to pay for the limited oral exam. You say that if the Plan covers necessary extractions, the Plan should also pay for the necessary exam that goes with it. 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 the limited oral exam once per plan year.   We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on March 2, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 26, 2021.   Your complaints about the Plan's frequency limit on the limited oral exam, and concerns about the Plan's policy and staff training are not valid appeals 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 18, 2021.  You asked the Plan to pay for the dental service. You say that you needed this service to determine if you could get dentures. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.  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 limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 12, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound preparation (15002) provided on September 13, 2021.  

You asked the Plan to pay for wound preparation. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.  

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 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.  

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 wound preparation. Our reviewer says that this code is not supported in the records. Our reviewer found the operative report does not include documentation of preparing a clean and viable wound surface for the placement of a graft.  The records document debridement of an open wound. There is a more appropriate code to report for these 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 wound preparation have not been met. Therefore, we decided that the Plan does not have to pay for wound preparation (15002) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the debridement services provided on August 9, 2021.  You asked the Plan to pay for the services provided. You say that medical documentation supports the code. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  In this case, the CPT Code Manual definition of code 11721 is debridement of nail(s) by any method(s); 6 or more. The file shows that CPT code 11721 was billed along with code 11056. We find that code 11721 may be eligible for payment when billed with this code pair. The claim information does not show the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for oral interpreter services provided to the enrollee on May 26, 2021.  You asked the Plan to pay for the services. You say that this has been covered in the past. The Plan denied your request. The Plan says services not related to the medical care of the enrollee are not covered.  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 T1013 is "Sign language or oral interpretive services, per 15 minutes."  We find that CPT code T1013 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for oral interpreter services provided to the enrollee on May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on July 30, 2021.  You asked the Plan to pay for the ambulance response without transport. You say that you expect reimbursement for your payment of this service. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When transport is not provided, there is no payable service under Medicare or under your Medicare Advantage Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on July 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on July 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance (A0429) and mileage (A0425), provided on June 20, 2021.  You asked the Plan to waive the copayment for the ambulance service. You say that you should not have to pay for this service. 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 $100 per a trip for ambulance serivces.   You have been asked to pay $100 per a trip for the ambulance service. This service falls within the ambulance serivces 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 ambulance (A0429) and mileage (A0425), provided on June 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on September 22, 2021.  You asked the Plan to waive the coinsurance for the Part B drug. You say that the copayment of $366.56 is very expensive and should be waived. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.   You have been asked to pay $366.56 which is 20% of the allowed amount for the Part B drug. The allowed amount is $1,832.82. ($1,832.82 x 20% = $366.56). The Part B drug 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 Part B drug provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies provided on July 12, 2021.  You asked the Plan to pay for the services provided. You say that the items were provided at your own cost. 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.  We looked at the file and the rules. We find that CPT codes A4550, 99072, A4456, A4457, A4649 are bundled codes. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. We find that CPT codes S1015 and S8301 are 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 supplies provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for intravenous infusion therapy (96365) provided from June 1, 2021, to July 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for intravenous infusion therapy. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for intravenous infusion therapy (96365) provided from June 1, 2021, to July 28, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoe insert (L3002), provided on August 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the shoe insert. You say that the item should be covered. The Plan denied your request. The Plan says there are in-network providers that could provide this item.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the shoe insert (L3002), provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the colonoscopy provided on March 30, 2021.  You asked the Plan to waive the copayment for the colonoscopy. You say that there should not be a copay. The Plan denied your request. The Plan says the copay way 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 $325 surgical service copay for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $325 surgical service copay for the colonoscopy. This service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on March 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the ambulance transportation services (A0428) provided on August 4, 2021, and August 5, 2021.  You asked the Plan to waive the copayments for the ambulance transportation. You say that these services were necessary, and you are dissatisfied with the care the enrollee was receiving in a facility. The Plan denied your request. The Plan says these claims were processed correctly, and the copayments were assessed in accordance with the enrollee's contract. A $225 copayment is required for each one-way ambulance trip. Please note that the Plan's allowed amount (discounted rate) for the trip provided on August 5, 2021, is less than the required copayment, and the enrollee has been asked to pay the lesser amount in that instance. The Plan also says that your grievance against the facility is addressed in a separate matter.   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 $225 copayment for each one-way ambulance trip.   The enrollee has been asked to pay a $225 copayment or less for each ambulance transportation trip. 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 the ambulance transportation services (A0428) provided on August 4, 2021, and August 5, 2021.
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 is not medically necessary.    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 based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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 laminectomy services coded 63048 and 63047 provided on May 13, 2021.  You asked the Plan to pay for the laminectomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 find that CPT code 63048 and 63047 is not supported in the medical record. Specifically, code 63047 is denied due to being submitted within the global period of surgery procedure code 63047 performed by the provider on March 9, 2021. Code 63048 is an add-on code that is performed in conjunction with another primary service by the same practitioner. An add-on code is only payable when the primary procedure is payable. Based on this information, we decided that Medicare rules for coverage of the laminectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the laminectomy services coded 63048 and 63047 provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist office visits (G0463) rendered from February 12, 2021, to August 13, 2021.  You asked the Plan to waive the copayments for specialist office visits. You say that you cannot afford to pay these copayments and you are very unhappy. 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 $45 copayment for each Medicare covered specialist office visit.   You have been asked to pay a $45 copayment for each specialist office visit, which totals $180 ($45 x 4 = $180). Specialist office visits fall under the physician/practitioner services, including doctor's office visit 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 copayments for specialist office visits (G0463) rendered from February 12, 2021, to August 13, 2021.