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

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 21, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you were informed by the ambulance crew that there would be no charge. The Plan denied your request. The Plan says you have been 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each ambulance stabilization when there is no transport. 

You have been asked to pay a $250 copayment for the ambulance services. Ambulance services fall within the Ambulance 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 copayment for ambulance services provided on August 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for over the counter (OTC) supplement, oligomeric
proanthocyanidins (OPC-3), provided on March 12, 2021.
You asked the Plan to reimburse you for OPC-3. You say that you use this for asthma. You also say that this
supplement is listed as a covered over-the-counter (OTC) item. The Plan denied your request. The Plan says
OPC-3 is not listed as a covered item in the Pick Your Perks program.
The Plan offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must
be included on the Plan's allowed items list. Ineligible items include alternative medicines such as botanicals,
herbals, probiotics and nutraceuticals.
The file shows that OTC items must be included on the Plan's allowed items list. Ineligible items include
alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. Therefore, we decided that the
Plan does not have to reimburse you for the over the counter (OTC) supplement, oligomeric proanthocyanidins
(OPC-3), provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for A1C and urine laboratory tests provided on August 17, 2021.

You asked the Plan to waive the deductible for the laboratory tests. You say that you received a letter from the Plan stating you could have AC1 and urine tests free of charge. The Plan denied your request. The Plan says the correct amount was applied to your deductible.

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 there is a $250 deductible which applies to the laboratory tests. 

The laboratory tests you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Please note that the letter you received was for a free home test kit, and the test analysis is still subject to the deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which applies to the laboratory services. This cost sharing is a contractual obligation that had not been met at the time the laboratory tests were performed on August 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for A1C and urine laboratory tests provided on August 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the lower extremities (93925) provided on July 14, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that this claim should have been paid at 100%. The Plan denied your request. The Plan says This claim was processed in accordance with your contract. There is a $125 copayment for ultrasounds.

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 $125 copayment for Medicare-covered radiological diagnostic services. 

You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the Medicare-covered radiological diagnostic 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 copayment for the ultrasound of the lower extremities (93925) provided on July 14, 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 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 that you were admitted for respiratory failure, sepsis, bacteremia, intestinal perforation requiring surgery and with wound dehiscence, and stroke. Medical problems are now stable. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for low back pain. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (procedure code 64450) provided to the enrollee on February 16, 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 denied code remains not supported, as the name of the patient is not in the records.
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 64450 is "Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch. We find that CPT code 64450 is not supported in the medical record. Specifically, the records do not contain the name of the enrollee. The records cannot be verified; therefore, it cannot be confirmed that the enrollee received CPT 64450. 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 injection services (procedure code 64450) provided to the enrollee on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services coded as 11044, 11043, 11046, 11042 and 17250 provided on August 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the wound care services. You say that the service rendered was medically necessary and care was provided as an urgent request to avoid wound complications. Kindly review the medical records attached which support the urgency and need for treatment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 wound care services coded as 11044, 11043, 11046, 11042 and 17250 provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (29828, 29823, and 29821) provided on July 8, 2021.
You asked the Plan to pay for codes 29828, 29823, and 29821. You say that the medical records support the billing of codes 29828 and 29823 and the use of modifier -59 with code 29821 provided on July 8, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 29828 and 29823 and the use of modifier -59 with code 29821 provided on July 8, 2021.

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 29828 is Arthroscopy, shoulder, surgical; biceps tenodesis. The definition of code 29823 is Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). The definition of code 29821 is Arthroscopy, shoulder, surgical; synovectomy, complete. 

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 codes 29828, 29823, and 29821. Our reviewer says that the medical records do not support the billing of codes 29828 and 29823 and the use of modifier -59 with code 29821 provided on July 8, 2021. Our reviewer found for code 29828, the operative report does not include enough detail of this procedure to confirm the bicep tendon was released and attached to humerous. Operative report documents "Biceps tendon had been previously at the beginning of the procedure released using the electrocautery". Therefore, this procedure cannot be confirmed. 

For code 29823, the operative report does not include documentation of extensive debridement to include 3 or more discrete structures. 

For code 29821, the operative report includes documentation to support this procedure, however this procedure is included in the approved CPT 29824. Documentation does not support this procedure as a distinct procedure to include different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 29828, 29823, and 29821 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services (29828, 29823, and 29821) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical stimulation device (TENS), and a pneumatic/vasopneumatic device provided to the enrollee on July 26, 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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found prolotherapy is believed to stimulate the body's ability to heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative processes. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered, which is like acupuncture. The TENS unit for neuromuscular conditioning is not considered a covered benefit. Pneumatic/vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical stimulation device (TENS), and a pneumatic/vasopneumatic device provided to the enrollee on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 6, 2021, to August 10, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you didn't receive treatment for the condition you were admitted for, so you shouldn't have to pay the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for four days. You were charged a $300 copayment per day, for a total of $1200. This copayment applies regardless of the reason for the admission and regardless of the extent
of services you receive. 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 services you received from August 6, 2021, to August 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carbidopa/Levodopa.

You asked the Plan to pre-approve Carbidopa/Levodopa. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.

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 pre-approve Carbidopa/Levodopa.

Benefits for Carbidopa/Levodopa 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on September 20, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the hospital for hernia repair surgery and were advised that you could not leave the hospital until you urinated. However, after surgery, the post-op person said it was ok for you to leave with hospital without urinating. Several hours later, you still could not urinate and were advised to go to the ER. You do not think you should have to pay the ER copayment because of this. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER 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 the emergency room (ER) visit you had on September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from
January 4, 2021, to January 17, 2021.
You asked the Plan to pay for the services. You say that the enrollee's rehabilitation has been affected by the
pandemic. The Plan denied your request. The Plan says the contractual language allows for 100 days per
benefit period; additional days are not approvable.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from 9/25/20 to
12/31/20. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from January 4,
2021, to January 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling for tooth # 25 provided on August 6, 2021.

You asked the Plan to pay for the dental service. You say that the filling was approved on a pre-treatment estimate. You also say that this service should be covered. The Plan denied your request. The Plan says replacement fillings are covered once per tooth every 2 years. The Plan also says that the frequency limit has been exceeded.

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 and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a filling for tooth # 25, for the mesial, incisal, labial, facial, or "MILF" surfaces, that you received on October 14, 2020. The record shows that the pre-estimate approval was for the "D", or distal surface, which was not performed. Therefore, we decided that the Plan does not have to pay for the filling for tooth # 25 provided on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement procedures you had at an outpatient hospital facility from May 7, 2021, to July 20, 2021.

You asked the Plan to waive the copayments for the wound debridement procedures. You say that the Plan should pay for all of your wound care treatment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that on each of the dates of service, the allowed amount for the services is less than your copayment obligation, so you are responsible for the full allowed 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 $335 copayment for surgery or other services at an outpatient hospital. 

You have been asked to pay a $335 copayment for the wound debridement procedures. Because these services occurred at an outpatient hospital facility, the outpatient hospital cost sharing applies. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for wound debridement procedures you had at an outpatient hospital facility from May 7, 2021, to July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder Detect test (procedure code 0012M) provided to the enrollee on June 21, 2021.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the CxBladder test is not covered. Medicare does not consider this test to be reasonable or necessary based on the current literature. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect test (procedure code 0012M) provided to the enrollee on June 21, 2021.