Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for individual psychotherapy (90832) provided June 9, 2021 to June 28, 2021.  You asked the Plan to pay for the psychotherapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there was no documented contact with the attending, primary care physician.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  We looked at the file, your request and Medicare rules. Based on this information we have decided that the rules for Medicare coverage of the psychotherapy services have not been met. The submitted claim does not include a referring provider for the services at issue. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy (90832) provided June 9, 2021 to June 28, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.  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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status and gangrene of first and second digits of right foot, which was managed with amputation of both digits. Medical problems are stable. There are no complex nursing or rehabilitation needs.   The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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 limited oral evaluation (D0140), provided on July 14, 2021.  You asked the Plan to pay for the limited oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered service.  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. Specifically, this service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 14, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for drug testing (G0483) provided on June 7, 2021.  You asked the Plan to pay for drug testing. You say that this is supported by the records. The Plan denied your request. The Plan says that the records do not show that 22 or more drug classes were tested.  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 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 supported in the medical record. Specifically, the records show that more than 22 drug classes have been tested. The tested classes include Alcohol biomarkers; Alkaloids, not otherwise specified; Amphetamines; Benzodizepines; Buprenorphine; Cannabinoids, natural; Cannabinoids, synthetic; Cocaine; Fentanyls; Gabapentin, non-blood; Heroin metabolite; Ketamine and Norketamine; Methadone; Methylenedioxyamphetamines; Opiates; Opioids and opiate analogs; Oxycodone; Phencyclidine; Pregabalin;l Propoxyphene; Sedative Hypnotics (non-benzodiazepines); Skeletal muscle relaxants; Stimulants, synthetic; Tapentadol; and Tramadol  Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on June 7, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for fluoroscopic guidance services (procedure code 77002) provided to the enrollee on March 22, 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 this is an add-on code without the appropriate primary procedure.  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 77002 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance services (procedure code 77002) provided to the enrollee on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an out-of-network provider on September 8, 2021.  You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your dentist retired and he referred you to this dentist. You say that they failed to tell you the dentist was out-of-network you should not pay $163. The Plan denied your request. The Plan says the services were received from an out-of-network provider.  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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an out-of-network provider on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network practitioner services provided to the enrollee on August 17, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network practitioner services provided to the enrollee on August 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 29, 2020, to November 13, 2020.  You asked the Plan to pay for the self-administered drugs. You say that as far as you know, everything was already paid. The Plan denied your request. The Plan says self-administered drugs provided in an outpatient setting are not covered under your Medicare Part B coverage. The Plan also says that they have confirmed with your provider that the services have been paid and you do not have a balance.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 29, 2020, to November 13, 2020.   Benefits for the self-administered drugs 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an inpatient hospital magnetic resonance imaging (MRI) of the abdomen (74183) rendered on November 4, 2020.  You asked the Plan to waive the deductible for an inpatient hospital magnetic resonance imaging. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan contract says that there is a $198 deductible for all items and services except those specifically excluded by the Plan contract.   You have been asked to pay a $46.07 deductible for an inpatient hospital magnetic resonance imaging. Inpatient hospital magnetic resonance imaging falls within the Inpatient Hospital Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible, which applies to an Inpatient Hospital 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 that had not been met at the time of the inpatient hospital magnetic resonance imaging rendered on November 4, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an inpatient hospital magnetic resonance imaging (MRI) of the abdomen (74183) rendered on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the provision of testing materials and equipment for home anticoagulation monitoring (code G0249) you received on May 31, 2021.  You asked the Plan to waive the coinsurance for the services to provide you with testing materials and equipment. You say that this should have been processed as durable medical equipment with 20% coinsurance instead of a $45 copayment. The Plan denied your request. The Plan says this was charged correctly.  The Plan says that the code billed is a physician service.  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 $45 copayment for physician specialist services.   You have been asked to pay a $45 copayment for the services to provide you with testing materials and equipment. Medicare rules explicitly state that the provision of testing materials and equipment for home anticoagulation monitoring (code G0249) is not considered a durable medical equipment code.  This is considered a physician service and paid by under the Medicare Physician Fee Schedule.  That is why the services to provide you with testing materials and equipment fall within the physician specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the provision of testing materials and equipment for home anticoagulation monitoring (code G0249) you received on May 31, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve replacement of endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848) addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase (L5856).  You asked the Plan to pre-approve the replacement of advanced knee and ankle. You say that the enrollee was denied for a microprocessor prosthesis but records document K3 function level and the ability to use a high activity foot and knee. The Plan denied your request. The Plan says that the computerized knee exceeds the enrollee's needs.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   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 replacement of advanced knee and ankle. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 53-year-old female with absence of right leg above knee. A request for a prosthesis with advanced leg and ankle components due to the current prosthesis is ill-fitting and is broken needing replacement. The enrollee is quite active with dancing, hiking, bicycling, caring for grandchildren, gardening, as well as walking and has been dependent on the K3 device for the past few years. Therefore, this enrollee meets the criteria for the advanced leg and ankle device.  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 replacement of advanced knee and ankle have been met. Therefore, we decided that the Plan has to pre-approve replacement of endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) addition to endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848) addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase (L5856).   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care services (procedure code 99291) provided to the enrollee on June 11, 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 code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes."  We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not include the time spent providing the critical care services. This information is required as CPT 99291 is a time-based code. 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 critical care services (procedure code 99291) provided to the enrollee on June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug injections provided on March 5, 2021.  You asked the Plan to waive the coinsurance for Medicare Part B drug injections. You say that you disagree with the charges because your treatment was fully approved with no cost to you. 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 Medicare Part B prescription drugs.   You received Medicare Part B drug injections on March 5, 2021. The total allowed amount is $314.31 and 20% of that is $62.86.   You have been asked to pay the total coinsurance amount of $62.86 for Medicare Part B drug injections. Medicare Part B drug 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 Medicare Part B drug injections provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81493) provided September 22, 2020.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this procedure is not covered.  The Plan must follow Medicare rules. Medicare rules say that the manufacturer has failed to demonstrate that testing resulted in improved patient outcomes and this test is non-covered.  We looked at the file and Medicare rules. The test performed is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81493) provided September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you $300 for a cool therapy machine (E0218) purchased on May 27, 2021.  You asked the Plan to reimburse you for this equipment. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says this equipment is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules specifically state a cold therapy pad is not covered by Medicare. While this item may be appropriate for your use, it is not an item covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you $300 for a cool therapy machine (E0218) purchased on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periapical radiograph images (D0220 and D0230), provided on June 10,2 021.  You asked the Plan to pay for the periapical radiograph images. You say that the services should be covered. 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. Specifically, the services are not listed in the Plan's benefit chart. This means they are not covered. Therefore, we decided that the Plan does not have to pay for the periapical radiograph images (D0220 and D0230), provided on June 10,2 021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visits (99204, 99213), the lumbar sacral orthosis (L0637), the x-ray exam of the lumbar spine (72100), and the x-ray exam of the pelvis (72170) rendered by the out-of-network (OON) provider on June 29, 2021 and July 20, 2021.  You asked the Plan to pay for these items/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 items/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 items/services at issue in this appeal. The Plan did not pre-approve the items/services 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 the office visits (99204, 99213), the lumbar sacral orthosis (L0637), the x-ray exam of the lumbar spine (72100), and the x-ray exam of the pelvis (72170) rendered by the out-of-network (OON) provider on June 29, 2021 and July 20, 2021.