Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses, anti-reflective coating, polycarbonate or equal lens and miscellaneous vision item provided on June 23, 2021.

You asked the Plan to pay for the progressive lenses, anti-reflective coating, polycarbonate or equal lens and miscellaneous vision item. You say that basic prescription eyewear is covered 100% and both representatives told you that you would be reimbursed without a problem. You say that you don't understand why this would be denied and want to be fully reimbursed the cost you paid up front. The Plan denied your request. The Plan says the services are not covered benefits and reimbursement cannot be issued.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers standard lenses. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses, anti-reflective coating, polycarbonate or equal lens and miscellaneous vision item have not been met. Specifically, these are considered upgrades and not covered standard lenses. Therefore, we decided that the Plan does not have to pay for the progressive lenses, anti-reflective coating, polycarbonate or equal lens and miscellaneous vision item provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided February 15, 2021.

You asked the Plan to pay for the acupuncture services. You say that these services were medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, this service requires that the enrollee's condition be chronic low back pain. However, this acupuncture was specifically performed for pain in the enrollee's right shoulder. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on June 17, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that you would have had to drive over 55 miles to see a participating dentist for the root canal, and you cannot drive that far. You also say that your participating dentist referred you to this treating provider. The Plan denied your request. The Plan says the intraoral x-ray is 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. The only x-rays covered under your plan are bitewing x-rays and panoramic x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with an otolaryngologist on June 3, 2021.

You asked the Plan to waive the copayment for the otolaryngology visit. You say that this was a follow-up visit for which you were told there should be no 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 $35 copayment for visits with a specialist.

Records show that you had a minor abscess procedure on April 20, 2021. According to Medicare rules, follow-up visits during the postoperative period are included in the cost of the surgery. The Medicare-allowed postoperative period for the procedure you had was 10 days. However, the follow-up visit you had was more than 10 days after the surgery. Because of this, the cost of the follow-up is not part of the surgery and separate cost sharing can apply. You have been asked to pay a $35 copayment for the otolaryngology visit. The otolaryngology visit falls within the visits with a specialist 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 visit you had with an otolaryngologist on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).

You asked the Plan to pre-approve a knee scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is a considered a convenience item.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
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 enrollee meets the criteria for IRF. The Plan
denied your request. The Plan says the denial of authorization for IRF service is correct.

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 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. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99231) provided to the enrollee on June 18, 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 was not billed with the appropriate modifier.

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 99231 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit." 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation does not support an unrelated service of the global package. Under CMS rules, the evaluation and management (E/M) service is related to the initial surgery, because it is a complication of the previous procedure. It is not separately reimbursed.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (procedure code 99231) provided to the enrollee on June 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on March 23, 2021.

You asked the Plan to waive the copayment for emergency room visit. You say that you are dissatisfied with the care you received and refuse to pay this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $110 copayment for emergency room visit. 

You have been asked to pay $110 copayment for emergency room visit. Emergency room visit falls within the Emergency 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 an emergency room visit provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit for the evaluation and management coded 99283 provided on December 22, 2020.

You asked the Plan to pay for the emergency department visit for the evaluation and management. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 99283 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

We find that CPT code 99283 is not supported in the medical record. Specifically, this code was billed with the primary diagnosis code M10.371 (Gout due to renal impairment, right ankle and foot). There is a code-first underlying condition note beneath category M10.3 (Gout due to renal impairment), which means the underlying condition should be sequenced first for all the codes under M10.3 category and code M10.371 should be sequenced second. Based on this information, we decided that Medicare rules for coverage of the emergency department visit for the evaluation and management have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit for the evaluation and management coded 99283 provided on December 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted with altered mental status due to West Nile encephalitis. The enrollee continues to
improve. The enrollee continues to receive acute care services, and these have not been denied. The medical
record does not indicate that the enrollee requires services that he is not currently receiving but that would be
available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service
cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the high frequency chest wall oscillation, includes all accessories and supplies (E0483), provided on May 22, 2021.

You asked the Plan to waive the coinsurance for the high frequency chest wall oscillation, includes all accessories and supplies. You say that the item should be covered. The Plan denied your request. The Plan says the cost share 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment (DME0 and related supplies. 

The enrollee has been asked to pay a 20% coinsurance for the high frequency chest wall oscillation, includes all accessories and supplies. the high frequency chest wall oscillation, includes all accessories and supplies falls within the durable medical equipment (DME0 and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the high frequency chest wall oscillation, includes all accessories and supplies (E0483), provided on May 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee not tried and failed the preferred step therapy drug - Retacrit.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Retacrit before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy provided by Phoenix Rehabilitation on June 23, 2021.

You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the claim should be reprocessed. The Plan denied your request. The Plan says The Plan says that payment for G0283, 97110 and 97122 has been approved. Code 97010 is considered bundled with the paid codes and bundled services are not eligible for separate reimbursement.

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 97010 is application of a modality to 1 or more areas; hot or cold packs.

We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided by Phoenix Rehabilitation on June 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on December 10, 2019. 

You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available in the service area. You say that 
the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. 
The Plan says the records do not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on December 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a genicular nerve block (64454) provided on February 10,
2021.

You asked the Plan to pay for a genicular nerve block. You say that the procedure at issue is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met
because the procedure at issue is experimental/investigational.

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 a genicular nerve block. Our reviewer says
that the requested service is not considered medically reasonable and necessary in this case. Our physician
reviewer found that the procedure at issue is considered experimental/investigational therapy as it is the subject
of ongoing clinical trials.

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 genicular nerve block have not been met. Therefore, we decided that the Plan
does not have to pay for a genicular nerve block (64454) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and management services and a radiological examination provided by a chiropractor on May 4, 2021.
You asked the Plan to pre-approve evaluation and management services and a radiological examination. You say that treatment with your primary physician and physical therapist did nothing to help relieve your pain. You say that you had multiple treatments with the chiropractor and were able to relieve the pain. You say that you saved the Plan money by going to the chiropractor. The Plan denied your request. The Plan says you received services that are not listed as covered under the chiropractic benefit.
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve evaluation and management services and a radiological examination provided by a chiropractor on May 4, 2021