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

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home services coded R0070.

You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an inappropriate place of 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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.

We find that CPT code R0070 is not supported in the medical record. Specifically, this code was billed with place of service 31 (Skilled Nursing Facility). This service should be billed with place of service 32 (Nursing Facility) for enrollees in a non-covered stay. This means this code was billed with an inappropriate place of service. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home services coded R0070.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).

You asked the Plan to pre-approve a complete upper and lower denture. You say that you would like the dentures covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for dentures.

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 complete upper and lower denture once every five plan years. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper and lower denture were previously covered on April 18, 2019.

Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper and lower denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a smart band wrist drive.

You asked the Plan to pre-approve a smart band wrist drive. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no need for this medical equipment.

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. It appears that this would be for a convenience purpose. Therefore, we decided that the Plan does not have to pre-approve a smart band wrist drive.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac stress test and echocardiogram (EKG) to be provided by a cardiologist.

You asked the Plan to pre-approve the cardiac stress test and EKG from a cardiologist. You say that the services being requested are medically necessary. The Plan denied your request. The Plan says they were not provided with a physician's order and the necessary medical information needed to support the request.

Medicare rules say that plans can require enrollees to get authorization before receiving services. The contract with the Plan says that in order to see a network specialist you must get approval in advance from your PCP. 

The requested provider in this case is a specialist. There is no evidence of a referral or advanced approval from your PCP to see this specialist. Therefore, we decided that the Plan does not have to pre-approve a cardiac stress test and echocardiogram (EKG) to be provided by a cardiologist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from July
14, 2021, to August 12, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you feel that you should
only owe the office copayment. 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 10%
coinsurance for Medicare Part B prescription drugs.

You received Medicare Part B drugs from July 14, 2021, to August 12, 2021, for a total of 5 visits. The total
allowed amount per each Medicare Part B drug is $140 and 10% of that is $14. The total amount you owe is:
$70.

You have been asked to pay the total coinsurance amount of $70 for Medicare Part B drugs. Medicare Part B
drugs 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 Medicare Part B drugs provided from July 14, 2021, to August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 6, 2021, to May 11, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford 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 $320 copayment for days 1-5 for inpatient hospital care.   You received inpatient hospital care from May 6, 2021, to May 11, 2021. Therefore, you are responsible to pay a $320 copayment for days 1-5 (May 6, 2021, to May 10, 2021). The total amount you owe is: $320 (copayment) x 5 (inpatient days) = $1,600.   You have been asked to pay the total copayment amount of $1,600 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 copayment for inpatient hospital care provided from May 6, 2021, to May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) coded 74181 provided on June 24, 2021.

You asked the Plan to pay for the MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

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 74181 for the MRI is a column II code to column I code 74183. 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 the magnetic resonance imaging (MRI) coded 74181 provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on August 18, 2021.  

You asked the Plan to waive the coinsurance for DME and related supplies. 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 20% coinsurance for DME and related supplies.   

You received DME and related supplies on August 18, 2021. The total allowed amount is $259.89 and 20% of that is $51.98.   

You have been asked to pay the total coinsurance amount of $51.98 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided March 22, 2021.  

You asked the Plan to pay for the x-ray. 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 71045 has a bundled relationship with code 71046. 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 an x-ray (71045) provided March 22, 2021.
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 you need more aggressive therapy. The Plan denied your request. The Plan says your care could be better provided in an outpatient or subacute facility.  

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 physician reviewer found that at the current functional level, you do 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. You have not gained any function so far and it is unlikely that you will be able to make any significant functional gains in the predicted 14-20 days 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay more for the health club membership provided on January 1, 2020.
You asked the Plan to pay more for the health club membership. You say that you sent the reimbursement request before March 31, 2021 and it took two months to get back with results. You say that you want additional reimbursement. The Plan denied your request. The Plan says that you will be reimbursed $197.50. The remaining amount has been denied since no additional proof of payment was received.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits up to $300 each calendar year. The Plan's rules for coverage of additional gym benefits have been met. The records show you paid $395 toward the health club membership in 2020. Therefore, we decided that the Plan has to pay an additional amount up to $300 for the health club membership provided on January 1, 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a power wheelchair (K0841).

You asked the Plan to pre-approve a power wheelchair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.

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. In this case, the Plan did not provide evidence that the enrollee is not receiving non-skilled care in the SNF. We find that the Plan has not provided enough information to show that the facility is not considered the enrollee's home residence per Medicare guidelines. Therefore, we decided that the Plan has to pre-approve a power wheelchair (K0841).

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: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the diagnostic colonoscopy (45378) provided on
April 19, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for a colonoscopy, endoscopy, and other diagnostic "scopic" procedures, including pulmonary function tests and thyroid function tests. The Plan says you must pay a $25 copayment for the diagnostic colonoscopy provided. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for a colonoscopy, endoscopy, and other diagnostic "scopic" procedures provided. Therefore, we decided that the Plan has to waive the copayment for the diagnostic colonoscopy (45378) provided on April 19, 2021.
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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740) and resin-based composite - three surfaces, anterior (D2332) provided May 11, 2021.  You asked the Plan to provide additional payment for the crown and filling. You say that the Plan is supposed to cover up to $2,000 every year for dental services. The Plan denied your request. The Plan says this service is not covered under your 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. The Plan covers fillings once per tooth surface every two years with 50% coinsurance.  We looked at the file and Medicare rules. You were asked to pay $55.50 ($111 total cost x 50% coinsurance = $55.50) for the filling. This means you have been asked to pay the correct amount for the filling. Therefore, we decided the Plan does not have to provide additional payment for the resin-based composite - three surfaces, anterior (D2332) provided May 11, 2021. Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are not among those covered under this benefit. Therefore, we also decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic (D2740) provided May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided August 21, 2020 to August 26, 2020 billed with DRG 871.  You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the DRG billed is not supported by the documentation.  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 A41.9 defined as Sepsis, unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the documentation does not support the principal diagnosis code billed. Our physician reviewer found the documentation supported an admission for pneumonia. The documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though sepsis was documented in the medical record, supporting documentation was not found within the record. This means that the principal diagnosis assignment of A41.9 Sepsis, unspecified organism was not supported by the documentation. Therefore, the DRG billed is not payable.   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 August 21, 2020 to August 26, 2020 billed with DRG 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MRI of the spinal canal and contents, cervical; and any joint of upper extremity with anesthesia (CPT code(s): 72141 x 1, 73221 x 2, and 01922 x 3) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the services. You say that you are in a lot of pain 24/7 due to a torn rotator cuff which has affected your quality of life. You state you are claustrophobic, and you have tried oral sedation twice, but both have failed. The Plan denied your request. The Plan says this is not a medical emergency and there is an in-network provider that can perform this exact service for you.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  Review of the file shows that the Plan has referred you to an in-network provider that can perform the service. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve MRI of the spinal canal and contents, cervical; and any joint of upper extremity with anesthesia (CPT code(s): 72141 x 1, 73221 x 2, and 01922 x 3) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) alveolopasty in conjunction with extractions, one to three teeth or tooth spaces, per quadrant (D7311) and two (2) surgical placements of implant body; endosteal implant (tooth 5 and 6) (D6010).

You asked the Plan to pre-approve dental services. You say that the dental report was made before you re-enrolled with the Plan. The Plan denied your request. The Plan says the services requested are not a covered benefit with your 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 pre-approve six (6) alveolopasty in conjunction with extractions, one to three teeth or tooth spaces, per quadrant (D7311) and two (2) surgical placements of implant body; endosteal implant (tooth 5 and 6) (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided by a PT assistant (PTA) on November 13, 2020.  

You asked the Plan to pay for the PTA services. You say that this should be paid due to medical necessity. The Plan denied your request. The Plan says this is not the correct code for this service.  

The Plan must follow Medicare rules. Medicare rules say that services rendered by a PTA must be billed by the supervising therapist. These cannot be billed by an NPP as these providers are not considered therapists.  

In this case, the services of this PTA were billed incident to an NPP's services. This is not allowed per Medicare rules. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided by a PT assistant (PTA) on November 13, 2020.