Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on March 9, 2021 and billed under Claim A for code 88305.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. We overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan says that this claim denied as a duplicate claim because the Plan has already paid for this service under a previous claim. The Plan states this service was paid on a previous claim which was billed by the same provider for the same date of service. The Plan included both claims for review which shows this service was billed by the same group and under the same specialty.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the codes. In this case, Claim A cannot be paid due to its association with a previous claim for the same enrollee on the same date of service for the same services performed by the same provider. Medicare billing criteria are not met.
Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on March 9, 2021 and billed under Claim A.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce any of the 20% coinsurance charged for radiation therapy provided from November 16, 2020, to December 30, 2020.
You asked the Plan to waive or reduce this coinsurance. You say that you were given the impression you would not be responsible for a lot of out-of-pocket costs. The Plan denied your request. The Plan says this cost share was charged based on the services billed by your provider and the Plan contract agreement. We partially overturned the Plans decision due to the case file lacking some required information. The Plan requested a reopen and provided the required information.
The Plan is correct in this case. 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 radiation therapy.
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 or reduce any of the 20% coinsurance charged for radiation therapy provided from November 16, 2020, to December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided the Plan does not have to pay for drug testing provided to the enrollee on November 5, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider billed this service inappropriately. After clinical review of the medical records, the service was determined to be coded incorrectly. This is a billing error on the part of the provider and the service is not reimbursable. According to our review, the records do not include definitive laboratory results for 22 or more drug classes to support the coding criteria for the code billed on date of service. There was a total of 11 drug classes counted from the laboratory results received.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. The Plan provided additional records with the reopen request to show only 11 drug classes were tested. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on November 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429 and A0425) provided to the enrollee on August 21, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. We overturned the Plans denial. The Plan requested a reopen.
The Plan states that this claim denied because the liability carrier has paid over the usual and customary amount for this service. Payment is calculated taking into consideration the payment made by the auto carrier and Plan's allowable amount. When combined, the auto carrier payment and Plan's payment should not exceed the normal allowable amount. The calculations show code A0429 billed with one unit equals $380.18 allowed and code A0425 billed with 3 units ($7.62 x3) equals $22.86 allowed. The total allowable amount is $403.04. The auto carrier paid $568.40 towards the $710.50 billed for this service, leaving a balance of $142.10. However, the auto carrier has paid over the $403.04 allowed amount, by $165.36.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case as the auto carrier or primary payer in this case has paid over the Medicare allowed amount for this service. No further reimbursement is required from the Plan. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429 and A0425) provided to the enrollee on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex spacer.  You asked the Plan to pre-approve a Vertiflex spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a Vertiflex spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has a body mass index of 50. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for home INR monitoring services  You asked the Plan to waive the copayments for home INR monitoring services. You say that you disagree with these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $25 copayment for non-radiological diagnostic services.   You have been asked to pay a $25 copayment for home INR monitoring services. The home INR monitoring services fall within the non-radiological diagnostic 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 copayments for home INR monitoring services
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an occlusal guard purchased on March 10, 2020.  You asked the Plan to pay for this item. You say that this claim for payment should be paid by the Plan. The Plan denied your request. The Plan says this claim was not filed timely based on the Medicare guidelines.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for this item was not filed until August 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an occlusal guard purchased on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an intermittent limb compression device (E0673) provided on April 12, 2021.  You asked the Plan to pay for an intermittent limb compression device. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0673) provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99201) and positioning cushion/pillow/wedge (E0190) provided April 26, 2021 to May 17, 2021.  You asked the Plan to pay for the office visit and positioning cushion. You say that you have had services done on your neck before, so you do not understand why the services are not covered. The Plan denied your request. The Plan says these items are not covered when rendered by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99201) and positioning cushion/pillow/wedge (E0190) provided April 26, 2021 to May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from May 11, 2020, to May 22, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of DRG 871 and diagnosis code B37.7.  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 DRG 871 (septicemia or severe sepsis without mv >96 hours with MCC) and diagnosis code B37.7 (candidal sepsis). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 871 and diagnosis code B37.7. Our physician reviewer found the records support an admission for unspecified pneumonia but are inconsistent and unclear regarding a diagnosis of sepsis. Although sepsis is noted in the history and physical, progress notes, and discharge summary, there is no supporting medical record documentation. No hypotension is documented, and the enrollee's platelets and total bilirubin were within normal limits. The records do not support the billing of DRG 871 and diagnosis code B37.7.   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 services rendered from May 11, 2020, to May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that they have covered 100 skilled nursing facility days during this benefit period.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that you received 100 days of SNF care during the benefit period from August 12, 2021 through August 30, 2021, September 2, 2021 through September 14, 2021, September 22, 2021 through October 14, 2021, October 19, 2021 through November 6, 2021, and November 10, 2021 through December 9, 2021. The Plan has covered 100 days of SNF care.        Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 you appear to be improving and more stable requiring only short-term additional acute care services that can be safely administered at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided April 29, 2021, to May 2, 2021.  You asked the Plan to pay for the critical care. You say that the coding is supported by the documentation. The Plan denied your request. The Plan says the documentation provided does not support the billing of 99291 for dates of service April 29, 2021 to May 2, 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.  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 critical care. Our reviewer says that the billing of the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes is not supported from April 29, 2021, to May 2, 2021. Our reviewer found that medical records are still needed to support service 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) on April 29, 2021, and April 30, 2021, due to lack of critical time documented and the lack of records for service dates May 1, 2021, and May 2, 2021.  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 critical care have not been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided April 29, 2021, to May 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for dialysis services provided from March 2, 2021, to March 30, 2021.  You asked the Plan to pay for dialysis services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.    We looked at the file and Medicare rules. No medical records have been submitted that document the services at issue. Based on this information, we decided that Medicare rules for coverage of dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for dialysis services provided from March 2, 2021, to March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Flex-Walk system (L5981), and addition (L5968).  You asked the Plan to pre-approve a Flex-Walk system and addition. You say that the items are medically necessary. The Plan denied your request. The Plan says the request exceeds the member's needs.  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. Our reviewer says that the items are not medically necessary. Our physician reviewer found the records indicate the enrollee requires a walker for ambulation and will continued to require a walker with the use of the requested prostheses; this is not consistent with a K3 ambulation status.  The Plan must follow Medicare rules. Medicare rules say that a microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Flex-Walk system and addition have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flex-Walk system (L5981), and addition (L5968).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for durable medical equipment purchased on June 25, 2021 from a commercial website.  You asked the Plan to pay for durable medical equipment purchased on commercial retail websites. You say that the Plan should pay for these items. The Plan denied your request. The Plan says these items were purchased out of network, without prior authorization from a retailer who is not a Medicare eligible provider.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. The Plan contract says that enrollees must use network providers and that durable medical equipment requires prior authorization.   You did not follow your Plan contract rules or Medicare rules when you purchased this equipment. The retail provider you purchased this equipment from is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for durable medical equipment purchased on Ebay.com on June 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ambulance transportation provided from February 10, 2020, to June 8, 2020.  You asked the Plan to waive the copayments for the ambulance transportation. You say that you were informed that for 2021 you are not being billed for gurney transport from the hospital to your residence. You say a plan supervisor recommended you file for reimbursement. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $195 copayment for each one-way ambulance service.   You have been asked to pay a $195 copayment for each ambulance trip. Ambulance transportation falls within the Ambulance 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 copayments for ambulance transportation provided from February 10, 2020, to June 8, 2020.