Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple accessories.  You asked the Plan to pre-approve a group 3 power wheelchair with multiple accessories. You say that the chair has been inoperable since September 2021. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power options. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 a group 3 power wheelchair with multiple accessories. Our reviewer says that a group 3 power wheelchair with multiple accessories is not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee uses a ventilator attached to a wheelchair. The enrollee is able to perform an effective weight shift. The enrollee does not use intermittent catherization. The enrollee does not require a power seating system for management of increased tone or spasticity. The enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.) a separate display, other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee 's upper extremity strength and function support that they can control any power options through their own switches. The request for the harness, controller, and electronics exceeds the enrollee 's medical needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 3 power wheelchair with multiple accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple accessories.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided on May 31, 2021.  You asked the Plan to pay for the direct skilled nursing services of a RN. The Plan denied your request. The Plan says the RAP claim was submitted on October 8, 2021 for the home health care period of May 31, 2021. The Plan also says that the RAP was submitted outside of the Centers for Medicare & Medicaid Services timeframe.  The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the direct skilled nursing services of a RN have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, May 31, 2021. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided on May 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical dressings provided from October 15, 2020, to November 30, 2020.  You asked the Plan to pay for the services provided. You say that durable medical equipment guidelines do not apply. The Plan denied your request. The Plan says the claims were not coded correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  In this case, the CPT Code Manual definition of code A6209 is Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing. We looked at the file and the rules. We find that CPT code A6209 was not billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgical dressings provided from October 15, 2020, to November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the inpatient hospital admissions and services provided from June 15, 2021, to June 18, 2021, and from June 18, 2021, to September 8, 2021.  You asked the Plan to waive the copayments for the inpatient care. You say that these services are unwanted and being forced on you against your will. The Plan denied your request. The Plan says these claims were processed correctly, and your copayments were assessed in accordance with your contract.  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 $365 copayment for each of the first five days of an inpatient hospital stay and a $350 copayment for each of the first five days of an inpatient mental health hospital stay.   You have been asked to pay $730 for the two-day inpatient hospital stay ($365 x 2 = $730) and a $1,750 for the inpatient mental health stay which exceeded five days ($350 x 5 = $1,750). Medical records were provided to support that these services were provided and were medically necessary. 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 the inpatient hospital admissions and services provided from June 15, 2021, to June 18, 2021, and from June 18, 2021, to September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulation to extra-spinal regions (98943) outpatient office visit (99213) provided May 5, 2021.  You asked the Plan to pay for the chiropractic services. You say that you are appealing non-payment of 99213 for maximum number of visits reached. There are no maximum visits in the Plan. Please reprocess. The Plan denied your request. The Plan says the benefit limit has been exceeded.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan offers a chiropractor benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 visits per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of chiropractic visits. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation to extra-spinal regions (98943) outpatient office visit (99213) provided May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81001, 82043, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on September 15, 2021.  You asked the Plan to pay for these 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81001, 82043, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on September 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided on July 1 to July 23, 2021.  You asked the Plan to waive the copayment for SNF care. You say that you cannot afford this copayment. The Plan denied your request. The Plan says the correct copayment was applied.  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 $184 copayment for each day of days 21 to 100 of Medicare-covered SNF stays.   You have been asked to pay $552, or a $184 copayment for each day of days 21 to 23 of a 23-day stay for SNF care. 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 skilled nursing facility (SNF) care provided on July 1 to July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing provided on July 19, 2021.  You asked the Plan to pay for the testing services. You say that the test informs clinicians about which medications may require adjustments. The Plan denied your request. The Plan says the test has not shown to be useful.  The Plan must follow Medicare rules. Medicare rules say that PGx testing is not considered reasonable and necessary merely on the basis of a patient having a particular diagnosis.   We looked at the file, and Medicare rules. In this case, the records do not indicate the testing was ordered based on clinical factors. Medications should be provided based on the presence of a diagnosis and should be adjusted based on a patient's response to the medication. It is not necessary to do genetic testing to provide or adjust medications. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing provided on July 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing visits (G0299) and skilled physical therapy visits (G0151) provided from May 25, 2021, to June 23, 2021.  You asked the Plan to pay for the home health services. You say that the services should be paid. The Plan denied your request. The Plan says the initial request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care. The Plan also says that the claim was denied correctly.  The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, May 25, 2021. Therefore, we decided that the Plan does not have to pay for the skilled nursing visits (G0299) and skilled physical therapy visits (G0151) provided from May 25, 2021, to June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on April 6, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 92929 (percutaneous transcatheter placement of intracoronary stent[s], with coronary angioplasty when performed; each additional branch of a major coronary artery [List separately in addition to code for primary procedure]) has a status indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the over-bed table (E0274), patient lift, electric with seat or sling (E0635), and medical supplies (0270) provided on August 9, 2021, and home health services (S9122) provided from August 21, 2021, to September 10, 2021.  You asked the Plan to pay for the durable medical equipment (DME) and home health services. The Plan denied your request. The Plan says the providers in this case are not certified Medicare providers. The Plan says that there are certified Medicare providers for both DME and home health services available in the enrollee's area. The Plan also says that payment cannot be made to a non-participating provider who is not certified with 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 providers at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the over-bed table (E0274), patient lift, electric with seat or sling (E0635), and medical supplies (0270) provided on August 9, 2021, and home health services (S9122) provided from August 21, 2021, to September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the glycosylated hemoglobin testing rendered on
June 16, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the glycosylated hemoglobin testing rendered on June 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 19, 2021. We also decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) recording provided from July 19, 2021, to September 15, 2021.
You asked the Plan to waive the copayments for the specialist office visit and EKG recording. You say that you went to this provider one time. 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 $50 copayment for each specialist office visit. Your contract with the Plan also clearly says that you must pay a $50 copayment for diagnostic procedures and test in a specialist office. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay $24.69, which is less than the $50 copayment for the EKG recording. The EKG recording falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for a specialist office visit provided on July 19, 2021. We also decided that the Plan does not have to waive the copayment for electrocardiogram (EKG) recording provided from July 19, 2021, to September 15, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pulp vitality test (D0460), and a limited oral evaluation (D0140) provided by an out-of-network provider on September 13, 2021.  You asked the Plan to pay for a pulp vitality test and a limited oral evaluation. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering services are not a covered benefit.  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 a pulp vitality test (D0460), and a limited oral evaluation (D0140) provided by an out-of-network provider on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on
September 20, 2021.
You asked the Plan to pay for the dental service. You say that your policy states you can get a panoramic x-ray once every 3 years. You say that this charge should be completely covered. You say that your dentist said this would be covered. You also say that had you known it would not be covered you would not have had the x-rays taken. The Plan denied your request. The Plan says the claim was denied correctly.
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 complete series x-ray is not among those covered under this benefit. Additionally, the record shows that you were not enrolled in the optional supplemental dental rider on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the office visit and debridement rendered on September 20, 2021 and September 27, 2021.  You asked the Plan to waive the coinsurance for these services. You say that you didn't choose this provider and didn't know he was out-of-network. The Plan denied your request. The Plan says the coinsurance was applied 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 50% of the total allowed amount per day, per provider for out-of-network Medicare-covered specialist office visit and 50% of the total allowed amount for out-of-network Medicare-covered surgical services.  Review of the file shows that you had an out-of-network specialist office visit and debridement on September 20, 2021. You have been asked to pay 50% of the total allowed amount for these services. These services fall within the out-of-network Medicare-covered specialist office visit and out-of-network Medicare-covered surgical services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.   The file shows that you had an out-of-network specialist office visit on September 27, 2021. You have been asked to pay 50% of the total allowed amount for these services. These services fall within the out-of-network Medicare-covered specialist office visit 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 office visit and debridement rendered on September 20, 2021 and September 27, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room services provided on October 26, 2020.  You asked the Plan to pay for the emergency room services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the services billed on the date of service at issue in this appeal.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. In this case, there were no medical records provided for the October 26, 2020, date of service. We are unable to verify if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on September 29, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on  September 29, 2021.