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

We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the enrollee on May 27, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services 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. In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (procedure code G0483) provided to the enrollee on May 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from August 7, 2021, through September 5, 2021.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the member required no nursing services, which would be considered skilled services by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that as of August 7, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis at a SNF level of care as of August 7, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, her functional improvement had plateaued as of August 7, 2021, and she did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of August 7, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from August 7, 2021, through
September 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a prophylaxis cleaning (D1110), an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) and a topical application of fluoride varnish (D1206) provided on July 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to reimburse you an additional amount for a prophylaxis cleaning, an adjunctive pre-diagnostic test and a topical application of fluoride varnish. You say that you are requesting reconsideration as the dental provider is in-network. The Plan denied your request. The Plan says there is no coverage for an adjunctive pre-diagnostic test. The Plan also says that the provider is OON. If you see an OON dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged fees when visiting an OON dentist.

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.

We looked at the file and Medicare rules. The EOC confirms that an adjunctive pre-diagnostic test is not covered under your benefit Plan. The records show that the provider is an OON provider, and the provider did not become an in-network provider until August 29, 2021. The EOC also confirms that if you see an OON provider, you pay 50% of the cost for listed covered services. The records also show that the allowed amount for a prophylaxis cleaning was $49. The Plan paid $24.50, and you are responsible for the remaining $24.50. The records also show that the allowed amount for a topical application of fluoride varnish was $48. The Plan paid $24, and you are responsible for the remaining $24. Based on this information, we decided that the Plan's rules for coverage of a prophylaxis cleaning, an adjunctive pre-diagnostic test and a topical application of fluoride varnish have not been met. Therefore, we decided that the Plan does not have to reimburse you an additional amount for a prophylaxis cleaning (D1110), an adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) and a topical application of fluoride varnish (D1206) provided on July 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 shingles vaccine provided on September 9, 2021.

You asked the Plan to pay for the shingles vaccine under Medicare Part B. You say that your doctor told you to get this vaccine. The Plan denied your request. The Plan says this vaccine is not covered under Part B.

Medicare does not pay for or provide the shingles vaccine under Medicare Part B. The Plan follows the same rules. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on September 9, 2021 under your Medicare Part B benefit. Benefits for the shingles vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital care provided from August 27, 2021, to August 31, 2021.
You asked the Plan to waive the copayments for inpatient hospital care. You say that you disagree with the because you were still in the hospital 4 days and paid $600 out-of-pocket. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $275 copayment for days 1-5 for inpatient hospital care.
You received inpatient hospital care from August 27, 2021, to August 31, 2021. Therefore, you are responsible to pay a $275 copayment for days 1-4 (August 27, 2021, to August 30, 2021). The total amount you owe is: $1,100. You have been asked to pay the total copayment amount of $1,100 for inpatient hospital care. Inpatient hospital care 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 copayments for inpatient hospital care provided from August 27, 2021, to August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on January 4, 2021, to January 9, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you met more of your maximum our-of-pocket amount. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $300 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay less than a $300 copayment per day for days 1-4 for an inpatient hospital stay. You are being asked to pay $710.64, which is less than your copayment amount of $1,500 ($300 x 5 days = $1,500), due to the member reaching their maximum out-of-pocket amount of $5,600. An inpatient hospital stay 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 an inpatient hospital stay provided by a participating provider on January 4, 2021, to January 9, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on July 26, 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 laboratory services rendered by the out-of-network (OON) provider on
July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee replacement surgery.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate advanced joint disease demonstrated by radiographic-supported evidence or magnetic resonance imaging.

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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet at least three of the criteria listed in the LCD guidelines. There are no recent exams provided for the left knee since 4/15/21. In addition, the x-rays of the bilateral knees dated 5/26/21 note medial compartment arthrosis with mild severity on the left. The 11/5/21 computed tomography scan of the left knee notes tricompartmental degenerative changes. The provided imaging studies do not corroborate severe pathology in the left knee. Additionally, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures for the left knee. Moreover, there is noted BMI of 41.35, with no follow-up documentation to indicate if weight loss has been tried. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left knee replacement surgery (27447) 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee replacement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a high efficiency toilet purchased for the enrollee.
You asked the Plan to pay for a high efficiency toilet. You say that the enrollee's bathroom needed to be updated with a higher toilet. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare does not cover raised toilet seats. Medicare does not pay for commercial toilets. Medicare does not pay for any items purchased from retail providers who are not Medicare eligible durable medical equipment providers. While the toilet purchased may be appropriate for the enrollee to use, it is not covered. Therefore, we decided that the Plan does not have to pay for a high efficiency toilet purchased for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from July 2, 2021, to July 27, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you signed a form that advised you that your financial liability would start on July 27, 2021. The Plan denied your request. The Plan says you were charged this copayment 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 $0 copayment per day for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services.

Records show that you were in the SNF for 25 days. You were not charged a copayment for the first 20 days. You were then charged a $184 copayment per day for each of the remaining 5 days, for a total of $920. The Notice of Medicare Non-Coverage you signed does not have anything to do with your cost sharing. Rather, this form is provided to you as notice of when the Plan will not cover your stay at all. That does not mean that you have no financial liability prior to the date on the notice. It just means that the Plan covered your stay, minus your applicable cost sharing, until the date on the notice. 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 skilled nursing facility (SNF) services you received from July 2, 2021, to July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for trigger point injections (20552, 20553) application of a modality to 1 or more areas; hot or cold packs (97010) electrical stimulation (unattended) (G0283) ketorolac tromethamine injection, per 15 mg (J1885) drugs unclassified injection (J3490) provided January 20, 2021 to April 7, 2021.
You asked the Plan to pay for the chiropractic services. You say that please see attached medical record showcasing the medical necessity of the services provided. The Plan denied your request. The Plan says these services 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 trigger point injections (20552, 20553) application of a modality to 1 or more
areas; hot or cold packs (97010) electrical stimulation (unattended) (G0283) ketorolac tromethamine injection, per 15 mg (J1885) drugs unclassified injection (J3490) provided January 20, 2021 to April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics (D6245), retainer crowns (D6740), extractions
(D7140) and intra-socket biological dressing placement (D7922) provided on January 19, 2021.
You asked the Plan to pay for the pontics (D6245), retainer crowns (D6740), extractions (D7140) and intrasocket
biological dressing placement (D7922). You say that radiation tooth decay was caused by medical
cancer and should be covered under medical. You say that you paid dental, and the Plan should pay you. The
Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontics (D6245), retainer crowns (D6740), extractions (D7140) and intra-socket biological dressing placement (D7922) provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement (11043) provided on April 14, 2021.
You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure 11043 is included within the global surgery package of procedure 10140.
The Plan must follow Medicare rules. Medicare rules say that follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery are included in the global surgery package. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the debridement have not been met. Specifically, CPT code 11043 was provided within the global surgery period of CPT code 10140. Therefore, we decided that the Plan does not have to pay for the debridement (11043) provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bone graft provided on August 19, 2021.

You asked the Plan to waive the copayment for a bone graft. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

The record shows that you received a bone graft on August 19, 2021, at an outpatient hospital facility. A bone graft is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. 

You have been asked to pay a $275 copayment for a bone graft. A bone graft 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 a bone graft provided on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (77001) provided June 17, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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. In this case, we have confirmed that code 77001 has a bundled relationship with code 70470. 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 radiology services (77001) provided June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided July 6, 2021 to August 3, 2021.
You asked the Plan to pay for the office visit. You say that your understanding of your benefits was that you had 18 visits for acupuncture. There are 9 listed, so you do not understand why 3 are denied. All visits were for acupuncture for your back injury, not other medical reasons. The Plan denied your request. The Plan says the naturopath visits billed are beyond the 6 allowed during a calendar year.
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for the services of a naturopath and the services are limited to 6 visits every calendar year. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) provided July 6, 2021 to August 3, 2021.