Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the x-ray services coded 71045 provided on September 19, 2021.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan is denying this claim due to the explanation of benefits (EOB) was not attached to the claim. No additional explanation was provided for why these services were denied. This means that Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the x-ray services coded 71045 provided on September 19, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the humidifier (E0562) provided on May 18, 2021.

You asked the Plan to pay for the humidifier. You say that you would like reconsideration because the full claim should be paid to you. The Plan denied your request. The Plan says that this equipment was billed without the required modifier.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the humidifier by a contract provider. The file does not show that the Plan provided notice that the humidifier would not be covered. Under Medicare rules, this means the humidifier is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the humidifier (E0562) provided on May 18, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 10, 2021 to February 8, 2021.

You asked the Plan to pay for home health services. You say that you would like reconsideration because you submitted the RAP on multiple occasions. The Plan denied your request. The Plan says a RAP has not been submitted.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the records submitted indicate that the RAP was submitted later than 5 days after the from date. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 10, 2021 to February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on September 14, 2021, through September 16, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you shouldn't have to pay anything. 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 $275 copay for each day one through six for inpatient hospital care. 

You have been asked to pay a $275 copay for each day one through six for the inpatient hospital care. This serivce falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on September 14, 2021, through September 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable defibrillator (C1777, C1722, 33249,
C1721).

You asked the Plan to pre-approve the implantable defibrillator. You say that the implantable defibrillator is
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that implantable defibrillators are covered when 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 implantable defibrillator. Our
reviewer says that the defibrillator is not medically necessary. Our physician reviewer found review of clinical
documents does not show that the patient meets implant criteria for defibrillator insertion according to current
guidelines.

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 implantable defibrillator have not been met. Therefore, we decided that the
Plan does not have to pre-approve an implantable defibrillator (C1777, C1722, 33249, C1721).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (80320) provided on September 2, 2020, and
December 2, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.

We looked at the file and Medicare rules. Code 80320 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. 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 the lab
services (80320) provided on September 2, 2020, and December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Selective catheter placement (36012) and the Venography services (75820-26-59 and 75825-26-59) provided on June 15, 2021.
You asked the Plan to pay for codes 36012, 75820-26-59, and 75825-26-59. You say that the medical records support the billing of codes 36012, 75825-26-59, and 75820-26-59 provided on June 15, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 36012, 75825-26-59, and 75820-26-59 provided on June 15, 2021.
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 is Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus). 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 codes 36012, 75820-26-59, and 75825-26-59. Our reviewer says that the medical records do not support the billing of codes 36012, 75825-26-59, and 75820-26-59 provided on June 15, 2021. Our reviewer found based on the documentation submitted for review, Medicare billing criteria have not been met. For CPT code 36012, the operative report describes angioplasty of common iliac external iliac and common femoral vein and does not describe selective catheter placement. Therefore, this procedure cannot be verified. For CPT code 75825, the operative report does not support this procedure as a separate procedure from CPT 37248 which includes all imaging and radiological supervision and interpretation necessary to perform the angioplasty. For CPT code 75820, the operative report does not support this procedure as a separate procedure from CPT 37248 which includes all imaging and radiological supervision and interpretation necessary to perform the angioplasty. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 36012, 75820-26-59, and 75825-26-59 have not been met. Therefore, we decided that the Plan does not have to pay for the Selective catheter placement (36012) and the Venography services (75820-26-59 and 75825-26-59) provided on June 15, 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 August 17, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you did not receive, nor did you administer to yourself any drug. You also say that this is why you are disputing the charge.

The Plan denied your request. The Plan says the drugs you received are 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 August 17, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for seven (7) physical therapy (PT) visits (97112, 97140, 97010) provided on July 8, 2021, to July 29, 2021.
You asked the Plan to waive the copayment for PT visits. You say that you are unwilling to pay the cost share for your PT visits. You also say that the services you received were a joke and you feel you should not be responsible for the copayments applied. The Plan denied your request. The Plan says the PT services were provided on the dates of service in question and the claims were submitted with an outpatient hospital place of service. The Plan also says the copayments you are being charged are correct.
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 $40 copayment per visit at an outpatient hospital setting for outpatient rehabilitation services.
You have been asked to pay a $40 copayment per visit for PT. The records show that you received 7 PT visits in an outpatient hospital setting. The EOC confirms $40 is the required copayment per visit. Your total cost share is $280 ($40 x 7 visits = $280). PT visits fall within the outpatient rehabilitation 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 seven (7) physical therapy (PT) visits (97112, 97140, 97010) provided on July 8, 2021, to July 29, 2021.
Your complaint about the PT you received from the provider 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on December 11, 2020

You asked the Plan to pay for the acupuncture services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage of the acupuncture 
services have not been met.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records provided only document a diagnosis of 
low back pain. There is no medical history provided that would support a diagnosis of chronic low back pain as 
required by Medicare rules. Therefore, we decided that the Plan does not have to pay for the acupuncture 
services provided on December 11, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99284) provided on August 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 99284 is a column II code to column I code 999285. 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 (99284) provided on August 5, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 1, 2021, through April 30, 2021.

You asked the Plan to pay for the home health services. You say that this should be paid as other payers do not apply this rule for claims. The Plan denied your request. The Plan says Medicare rules are used for the enrollee's benefits. This means that the RAP was not submitted timely, and payment for the episode of care cannot be made.

The Plan must follow Medicare rules. Medicare rules say that RAPs must be submitted to the Plan within 5 days of the From date of the home health episode of care. For each day beyond this, 1/30th of the payment for the episode will be deducted.

The From date of this episode was April 1, 2021. A RAP was not submitted within 5 days of this date. Since more than 30 days passed before the RAP was submitted, no payment can be made for this episode of care. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 1, 2021, through April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical supplies provided on 
September 10, 2021.

You asked the Plan to waive the coinsurance for the medical supplies. 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 20% 
medical supplies coinsurance for outpatient diagnostic tests and therapeutic services and supplies.
 
You have been asked to pay a 20% medical supplies coinsurance for the medical supplies. These items fall 
within the outpatient diagnostic tests and therapeutic services and 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 the medical supplies provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic cardiovascular screening test provided on
December 14, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
screening test.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The testing at issue in this appeal, the genetic cardiovascular test, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the genetic cardiovascular screening test provided on December 14, 2020.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the LTACH 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for podiatry services provided from June 11, 2021, to July 29, 2021.

You asked the Plan to waive the deductible for the podiatry services. The Plan denied your request. The Plan says the correct amount was applied to your deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to certain items and services. 

The podiatry services you asked the Plan to waive the deductible for fall within the Podiatry Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the podiatry services were received on June 11, 2021, to July 29, 2021.

Therefore, we decided that the Plan does not have to waive the deductible for podiatry services provided from June 11, 2021, to July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on August 12, 2021, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth office visit provided on June 4, 2021, by an
OON provider.
You asked the Plan to pay for the telehealth office visit. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 telehealth office visit provided on June 4,
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on June 21, 2021.
You asked the Plan to pay for the chest x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The documentation shows that this chest x-ray was part of a pre-operative examination. The chest x-ray was provided in an absence of signs or symptoms. This means that the chest x-ray at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on June 21, 2021