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

 We decided that the Plan does not have to waive the coinsurance for surgical services provided May 18, 2021.  You asked the Plan to waive the coinsurance for the surgical services. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.      You have been asked to pay a 20% coinsurance for surgical services (allowed amount is $1,404.36 x 20% = $280.8). 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 surgical services provided May 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the office visits provided from April 12, 2021, through May 10, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $40 copayment for each Medicare-covered individual or group visit for outpatient mental health care.    You have been asked to pay $120 ($40 copayment x 3) for the Medicare-covered individual visits for outpatient mental health care provided. 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 the office visits provided from April 12, 2021, through May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided October 4, 2021.  You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. No medical records were provided to support the procedure. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that you have incontinence and take fluid pills for congested heart failure. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 10, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 10, 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 10, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 10, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond February 10, 2022, as he was not a danger to himself 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 the enrollee's 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 10, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 10, 2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dexilant.  You asked the Plan to pre-approve Dexilant. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  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 Dexilant.   Benefits for Dexilant 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve destruction by neurolytic agent (64634).  You asked the Plan to pre-approve destruction by neurolytic agent (64634). You say that the requested procedure is supported when a treatment plan shows the region (cervical, thoracic, or lumbar spine) and spinal level(s) to be treated or when no more than two levels of the spine will be injected on the date of service. The Plan denied your request. The Plan says the radiofrequency ablation procedure represented by CPT code 64634 cannot be approved.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 destruction by neurolytic agent (64634). Our reviewer found that there is no documentation at the third level of diagnostic medical branch blocks. Therefore, the request for a third level radiofrequency ablation is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent (64634) have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent (64634).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic evaluation (D0120), and bitewing x-rays (D0274) provided on September 16, 2021, by an out-of-network provider.
You asked the Plan to pay for out-of-network dental care. You say that you saw this provider previously and you did not know that they were no longer part of your plan's network. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's dental network. Services are only covered when performed by providers in the specified network.
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 only covers dental services which are provided in-network. Though the Plan offers a dental benefit in excess of Medicare coverage, services rendered by out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), periodic evaluation (D0120), and bitewing x-rays (D0274) provided on September 16, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care visit provided on July 29, 2021.  You asked the Plan to waive the copayment for the primary care visit. You say that the services should be covered as you were under the impression that there was a $0 charge for visits with your primary care physician. 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 Physician/Practitioner services, including doctor's office visits.        You have been asked to pay a $10 copayment for the primary care visit. Primary care visits fall within the 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 a primary care visit provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient services provided from April 30, 2021, to May 3, 2021.  You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Medicare says that the OCE will return to the provider any claim that reports a HCPCS code for a procedure assigned to a device-intensive APC, for which the procedure requires the implantation of a device that does not also report at least one device HCPCS code required for that procedure. In this case, Medicare procedure/device coding requirements have not been met as procedure code 31647 must be reported with a qualifying device code. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from April 30, 2021, to May 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0428) provided on August 27, 2021.  You asked the Plan to waive the copayment for the ambulance transportation services. 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 $200 copayment for Ambulance services.     You have been asked to pay a $200 copayment for ambulance transportation services. 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 ambulance transportation services (A0428) provided on August 27, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve outpatient physical therapy services (97110, 97162) to be provided by an out-of-network provider.  You asked the Plan to pre-approve out-of-network physical therapy. You say that this provider is closer to your home, and travel has become more difficult for you. The Plan denied your request. The Plan says that the requested services are not urgent or emergent and can be performed by providers in your medical group. The Plan also says that you live out-of-area for your medical group, and you have been contacted multiple times to discuss transferring your care to a group closer to your current home location. The provider who has been approved for these services is local to your medical group and you have regularly traveled 91 miles to get to your primary care physician, so this this travel should also be manageable.  Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers.   The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers located within reasonable distance and travel time from your home who can provide physical therapy. While you may not be within the area of your Plan's medical group, you are still within a county that is served by your Plan. While Medicare does say that a plan can create a medical group or primary care group to coordinate an enrollee's care, it does not say that this can be used to deny other care or make the enrollee go outside of the accessibility time/distanare not accessible to you. Therefore, we decided that the Plan has to pre-approve outpatient physical therapy services (97110, 97162) to be provided by an out-of-network provider.   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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided form June 13, 2020, to June 22, 2020.
You asked the Plan to pay for the inpatient care. You say that the diagnosis codes are supported. The Plan denied your request. The Plan says the provided documentation does not support the billed diagnosis.
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 diagnosis code A41. 9, defined as sepsis, unspecified organism, and diagnosis code R65.20, defined as severe sepsis without septic shock. 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 care. Our reviewer says that the billing of the diagnosis codes are not supported. Our physician reviewer found the provided documentation does not indicate there is any evidence of sepsis. The reviewer found that the documentation did not support the billing of diagnosis code A41. 9, Sepsis, unspecified organism. The reviewer also found that the documentation did not support the billing of diagnosis code R65.20, Severe sepsis without septic shock. 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 acute inpatient hospital care provided form June 13, 2020, to June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 31. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an office visit provided on March 24, 2021.  You asked the Plan to waive the deductible the office visit. You say that the services should be covered as an annual wellness exam. 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. Your contract with the Plan says that there is a $250 deductible which applies to Physician/Practitioner Services, Including Doctor's Office Visits.           The item or service you asked the Plan to waive the deductible falls within the benefit category Physician/Practitioner Services, Including Doctor's Office Visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which applies to Physician/Practitioner Services, Including Doctor's Office Visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on March 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug tests (80307, G0480) rendered by the out-of-network (OON) provider on August 11, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug tests (80307, G0480) rendered by the out-of-network (OON) provider on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services (97810) to treat dizziness and giddiness provided from June 25, 2021, to July 1, 2021  You asked the Plan to pay for the acupuncture services (97810). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered for the enrollee's diagnosis.  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, Medicare-covered acupuncture services are only covered to treat chronic low back pain. The file shows that the enrollee received these acupuncture services to treat dizziness and giddiness. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810) to treat dizziness and giddiness provided from June 25, 2021, to July 1, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on August 25, 2020.  You asked the Plan to pay for the laboratory 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 codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Skilled Nursing Facility, place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 provided on August 25, 2020.