Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided from August 28, 2020, to September 1, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not supported.  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. 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 services. Our reviewer says that the use of diagnosis code A41.9 is not supported by the records provided. Our physician reviewer found that the enrollee is a 76-year-old male who was treated in the hospital for chest pain, bowel distension, stage 2 pressure ulcer, and pneumonia. He denied shortness of breath or nausea/vomiting. The enrollee was also treated with conservative care during workup. The use of diagnosis code A41.9 (sepsis) is not supported by the records provided as the enrollee had no clear signs of sepsis, including evidence of organ failure.   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 services provided from August 28, 2020, to September 1, 2020.
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 services 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 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. Insufficient clinical documentation was provided to support the billed code. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services (A4649, M0240, G0378) provided on September 8, 2021.  You asked the Plan to pay for hospital services. You say that you were too distressed to find another facility. The Plan denied your request. The Plan says the provider of the services at issue is not enrolled in Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for hospital services (A4649, M0240, G0378) provided on September 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 1, 2020, to December 6, 2020.  You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the Daily Skilled Note dated on 11/14/20 documents that indoor mobility/ambulation is "unknown." The documentation insufficient to support that the enrollee's usual walking performance was with partial/moderate assistance.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from December 1, 2020, to December 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0429) provided on October 2, 2021.  You asked the Plan to waive the copayment for the ambulance transportation services. You say that the services should be covered as you were not satisfied with them. 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 $250 copayment for Ambulance services.     You have been asked to pay a $250 copayment for the 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 (A0429) provided on October 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care  You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.  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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are not on intravenous medications and you do not require complex wound care. Daily skilled services are not required. You are walking household distances with contact guard assistance. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
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 IRF care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.  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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient is in her private home on outpatient medications with no documentation that supports that she requires a physician's evaluation three or more times per week. Although the patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Care in the home with home health care or at the skilled nursing facility level appears to be appropriate in this case.       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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630 x2) provided on October 13, 2021.  You asked the Plan to pay for the scaling, gingival irrigations, and drugs or medicaments. You say that the dentist informed you that the scaling and gingivitis treatments were medically necessary before they could perform any routine cleanings. You also say that you were informed the treatments would be covered under the Plan. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.  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 scaling in presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630 x2) provided on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the port flush services you received in an oncologist's office on September 29, 2021.  You asked the Plan to waive the copayment for the oncology services. You say that you said that you have never been billed for a port flush before. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that their claims system should have charged you cost sharing for previous services, but there was an error calculating your maximum out of pocket 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 $25 copayment for medical care in a specialist's office.    You have been asked to pay a $25 copayment for the oncology services. The oncology services fall within the medical care in a specialist's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the port flush services you received in an oncologist's office on September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray you had on September 24, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that this cost is too much for you. 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 up to a $30 copayment for x-rays.

You have been asked to pay a $25 copayment for the x-ray. 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 x-ray you had on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy (90837) provided on August 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the rendering provider is a non-participating provider and there is no referring provider involved in these services. The Plan also says they did not authorize any services for this provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy (90837) provided on August 6, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to hold you harmless for the overpayment of $397 for dental services provided from March 3, 2020, to October 28, 2020.  You asked the Plan to hold you harmless for the overpayment for dental services. You say that you paid for the services upfront. You say that the total amount of the services you received is less than what you paid. You also say that you should be reimbursed for the $397 that you overpaid. The Plan denied your request. The Plan says that the claims were processed correctly.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the dental services by a contract provider. The file does not show that the Plan provided notice that the overpayment for dental services would not be covered. Under Medicare rules, this means the overpayment for dental services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the overpayment of $397 for dental services provided from March 3, 2020, to October 28, 2020.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiac genetic testing provided on April 13, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered screening test.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac genetic testing provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for bevacizumab 10mg injections (J9035) provided on September 21, 2021, and October 26, 2021.  

You asked the Plan to waive the coinsurance for the bevacizumab 10mg injections. You say that the services should be covered as you thought they would be always 100% 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 Medicare Part B prescription drugs.     

You have been asked to pay a 20% coinsurance for two bevacizumab 10mg injections (the total allowed is $155.11 x 20% = $31.02). Bevacizumab 10mg injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for bevacizumab 10mg injections (J9035) provided on September 21, 2021, and October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a privacy flap for a wheelchair (K0108).  You asked the Plan to pre-approve the privacy flap for a wheelchair. You say that this item is medically necessary. The Plan denied your request. The Plan says this accessory does not serve a medical purpose and is non-covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a privacy flap for a wheelchair (K0108).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services received on November 10, 2020.  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 denied codes remain not supported.  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 the denied codes is:  CPT 36140:  Introduction of needle or intracatheter, upper or lower extremity artery  CPT 36247:  Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family CPT 37253:  Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)  CPT 75710:  Angiography, extremity, unilateral, radiological supervision and interpretation  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 36140 is inclusive to another procedure reported.  Introduction of needle intracatheter would be performed with the revascularization of a unilateral femoral or popliteal artery, therefore, modifier -59 cannot be verified, as this service was not performed as a distinct service. The procedure report does not include documentation of CPT 36247. The procedure report does not describe (per NCCI Policy Manual) a guidewire threaded through the needle into a noncoronary blood vessel and removed, intravascular ultrasound catheter is placed over the guide wire. The procedure report does not support modifier -59 for CPT 75710.  Therefore this procedure would be inclusive to the primary procedure and not separately reported.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services received on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the 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 the enrollee appears to be improving to some extent but is still unstable and critically ill and requires short-term additional acute care services that can safely be received at the current facility until more stable. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when the enrollee is more stable and when treatment has completed.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for Supartz injections (J7321).  You asked the Plan to pay for the Supartz injections. You say that the injection is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that hyaluronic acid injections will only be covered for the treatment of pain in osteoarthritis of the knee. All other uses will be denied as investigational.  We looked at the file and Medicare rules. The injections are requested for treatment of the hand. This treatment is only covered for the knee. Based on this information, we decided that Medicare rules for coverage of the Supartz injections have not been met. Therefore, we decided that the Plan does not have to pay for Supartz injections (J7321).