Persius/hicric huggingface dataset:
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (CPT code 99203) provided on February 2, 2021, by an in-network provider.
You asked the Plan to waive the copayment for the office visit. You say that there were technical issues during the visit and the doctor told you there was nothing else they could do to help you. The Plan denied your request. The Plan says they called the doctor's office and were told in the doctor advised you that due to kidney and cardiovascular risk, the doctor recommended that you take nonsteroidal anti-inflammatory drugs (NSAIDs) and alternative treatment such as acupuncture or cupping. The Plan states the doctor advised you were not a candidate for opioid medication due to kidney and cardiovascular risk and recommended you follow up with a neuropsychologist.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the office services on February 2, 2021, by an in-network provider. You were asked to pay a $35 copayment for the in-network office visit. Your 2021 EOC states that enrollees must pay a $35 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). Although you were dissatisfied with the quality of care and services you received, the provider did render services to you and is allowed to bill the plan for the services. The Plan states our concerns regarding the care and services you received was reviewed in separate case. 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 office visit (CPT code 99203) provided on February 2, 2021, by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a surgical extraction (D7210) by an out-of-network (OON) provider.
You asked the Plan to pre-approve a comprehensive oral evaluation and a surgical extraction. You say that you were referred to see an oral surgeon. You also say that a tooth broke off and roots from the broken tooth are still present which makes it hard for you to eat. The Plan denied your request. The Plan says coverage for dental services is provided when performed by a participating provider. The Plan also says that dental services performed by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a comprehensive oral evaluation and a surgical extraction when the services are rendered by a participating provider.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and a surgical extraction have not been met. Specifically, you must see a participating provider to receive dental services. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a surgical extraction (D7210) by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), a bitewing image (D0274) and a periapical first radiographic image (D0220) provided on May 24, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a periodic oral evaluation, prophylaxis, a bitewing image and a periapical first radiographic image. You say that you have been going to the same facility using your current Plan and the provider recently changed to OON. You also say that you would like to get an exception to accept this claim due to the lack of communication about this provider. The Plan denied your request. The Plan says services performed by an OON provider are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a periodic oral evaluation, prophylaxis, a bitewing image and a periapical first radiographic image when the services are rendered by a participating provider. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, prophylaxis, a bitewing image and a periapical first radiographic image have not been met. Specifically, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), a bitewing image (D0274) and a periapical first radiographic image (D0220) provided on May 24, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that you have several visits to see your primary care physician and other specialists. You also say you will need additional transportation for these visits. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. The records show that you have used fifty-nine (59) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 trips are used, the benefit will be exhausted. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a wheelchair rental fee and a wheelchair seat cushion (CPT code(s): K0001 X 3, and E2601) provided to the enrollee from March 26, 2021, through May 26, 2021.
You asked the Plan to waive the copayment for the DME. You say that the skilled nursing facility who provided the wheelchair should have educated them prior to issuing the wheelchair upon discharge that a monthly rental fee would be assessed. The Plan denied your request. The Plan says the claims were processed accordingly with the enrollee's 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee was charged for the DME on March 26, 2021.
The enrollee has been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $76.45. The total the enrollee owes is $15.29 ($76.45 x 20% = $15.29). The enrollee was charged for the DME on April 26, 2021. The allowed amount is $32.93. The total the enrollee owes is $6.59 ($32.93 x 20% = $6.59). The enrollee was charged for the DME on May 26, 2021.The allowed amount is $33.21. The total the enrollee owes is $6.64 ($33.21 x 20% = $6.64). The enrollee's total cost share responsibility is $28.52 ($15.29 + $6.59 + $6.64 = $28.52). The enrollee's 2021 EOC states that enrollees must pay 20% for each Medicare-covered DME item from a DME provider. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a wheelchair rental fee and a wheelchair seat cushion (CPT code(s): K0001 X 3, and E2601) provided to the enrollee from March 26, 2021, through May 26, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the TruGraf test provided on September 3, 2020.
You asked the Plan to pay for the TruGraf test. You say that this is medically necessary. The Plan denied your request. The Plan says criteria for this testing are not met.
The Plan follows Medicare rules. Medicare rules say that the TruGraf test is covered when the indications are met 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 pay for the TruGraf test. Our reviewer says that the documentation is not sufficient to support that the criteria are met. Our physician reviewer found the testing was provided for a renal transplant patient with good allograft function. There is not sufficient documentation in the records enclosed that support an indication for the test. 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 TruGraf test have not been met. Therefore, we decided that the Plan does not have to pay for the TruGraf test provided on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the critical care services provided on February 15, 2021, and February 16, 2021, reported with one unit of code 99292 and two units of 99292, respectively.
You asked the Plan to pay for the critical care services provided. You say that this is correctly billed as the main physician is billing for the services of the critical care nurse practitioner (NP). Another claim was submitted for the physician's time using 99291, but a separate claim was required to report the time spent by the NP. The Plan denied your request. The Plan says that the submitted medical records document 59 minutes of critical care time. They do not support that an additional 30 minutes of critical care services was performed in addition to the first 30-74 minutes of a critical care evaluation and management 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, the CPT Code Manual definition of code 99292 is Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that the number of units of 99292 for both dates are supported by the record. The progress notes clearly indicate that the enrollee was seen by two critical care providers for each date of service. In this situation, one provider bills for 99291 and 99292 (if applicable) while the second provider bills their time spent with 99292. The NP documented 59 minutes of critical care time for February 15, 2021, which supports the billing of at least the 30 minutes on the claim. The February 16, 2021 progress note documents 58 minutes, which supports the one hour of time billed on the claim. Based on this information, we decided that Medicare rules for coverage of the critical care services provided have been met. Therefore, we decided that the Plan has to pay for the critical care services provided on February 15, 2021, and February 16, 2021, reported with one unit of code 99292 and two units of 99292, respectively.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services provided on March 22 - April 26, 2021.

You asked the Plan to pay for the acupuncture services. You say that the Plan's coverage says that acupuncture is a covered benefit. The Plan denied your request. The Plan says the medical records they received do not indicate that the enrollee received acupuncture for chronic low back pain.

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 show that you received acupuncture for the treatment of chronic migraines, neck pain, chest pain, kidney pain, stomach issues, severe TMJ with arthritis, cystitis, and apnea. Therefore, we decided that the Plan does not have to pay for acupuncture services provided on March 22 - April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy rendered on May 17, 2021.

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 services are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code 97014 (electric stimulation therapy) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy rendered on May 17, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Triluron sodium hyaluronate injections provided on April 7, 2021, and April 14, 2021 billed with code J7332.

You asked the Plan to pay for the Triluron (J7332). You say that this is payable, and no valid reason was given for the denial. The Plan denied your request. The Plan says that this is not payable per the Medicare rules.

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. The Plan has not submitted a valid denial rationale in this case. The Plan has stated that this is not payable due to the status indicator in the Outpatient Prospective Payment System (OPPS). However, this drug was not provided in the hospital setting, and has not been billed by a facility, but by a physician. Drugs provided in a physician's office are not paid via the OPPS; therefore, this payment indicator is not material to the issue of coverage in this case. As noted, drugs billed by a physician are priced based on the ASP methodology. Therefore, we decided that the Plan has to pay for the Triluron sodium hyaluronate injections provided on April 7, 2021, and April 14, 2021 billed with code J7332.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) (CPT code 78451), technetium tc-99m sestamibi, diagnostic, per study dose (CPT code A9500) and dardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report (CPT code 93017) provided on June 17, 2021.
You asked the Plan to waive the copayment for the services. You say that you were billed $45 for a test that was not completed. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received perfusion imaging on June 17, 2021. Although the full study was not complete, your medical records show that you still received services. You were asked to pay a $45 copayment for the services. Your 2021 EOC states that enrollees must pay a $45 copayment per provider, per date of service for routine radiology (x-ray, radiology, diagnostic services, ultrasounds). 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 CPT code 78451, CPT code A9500 and CPT code 93017, provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Synvisc-One 1MG injection (CPT code J7325) and arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610) provided on July 12, 2021.
You asked the Plan to waive the copayment for the services. You say that you did not ask for this injection, they inflicted excruciating pain and suffering on you. The Plan denied your request. The Plan says you were
warned the provider that the injection may not improve your pain. The Plan states you received the claim was
processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you receive specialist office services and Synvisc-One 1MG injection on July 12,
2021. You were asked to pay a $25 copayment for the specialist office visit and 20% coinsurance for the
injection. Your 2021 EOC states enrollees must pay 20% coinsurance for Part B covered drugs; including Part
B covered chemotherapy and a $25 copayment for each specialist visit. 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 Synvisc-One 1MG injection (CPT code J7325) and arthrocentesis, aspiration and/or injection,
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code
20610) provided on July 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021.
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 services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021.