Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services coded G0156 provided from September 7, 2020 to September 11, 2020.

You asked the Plan to pay for the home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes.

We find that CPT code G0156 is not supported in the medical record. Specifically, the documentation does not include the time spent on these services rendered. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services coded G0156 provided from September 7, 2020 to September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on June 9, 2021.

You asked the Plan to waive the copayment for the laboratory work. You say that this was regular laboratory work at the medical center, not a hospital. You say this has always been covered. The Plan denied your request. The Plan says you have been asked to pay 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 laboratory services at an in-network outpatient hospital.

You have been asked to pay a $50 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by an in-network outpatient hospital. 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 laboratory work provided on June 9, 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 requested admission to an IRF is not medically necessary.

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. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 scaling and root planning (D4341), provided on July 6, 2021.

You asked the Plan to pay for the scaling and root planning. You say that the services should be covered. The Plan denied your request. The Plan says your applicable annual defined contribution amount 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, the requested items or services are not among those covered under this benefit. Specifically, you exceeded the Plan's applicable annual defined contribution amount and are responsible for the difference. Therefore, we decided that the Plan does not have to pay for the scaling and root planning (D4341), provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the feeding supplements, parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein, premix (B4189).
You asked the Plan to pre-approve the feeding supplements. You say that due to this enrollee's severe malnutrition, this enrollee is at high risk for recurrent hospitalizations. The Plan denied your request. The Plan says the medical necessity criteria not met as there are no current clinical notes from the physician and the appeal is from the durable medical equipment provider.
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 the feeding supplements. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the member is on continuous cycling peritoneal dialysis and physician has ordered Intraperitoneal Nutrition in conjunction with the dialysis. Notes on 6/17/2021 state that she is not a candidate for tube feeding and the reason for her malnourishment is due to the hypoalbuminemia and clinical malabsorption. There are no current clinical notes from the physician were provider. The appeal is from the DME company. The medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 feeding supplements have not been met. Therefore, we decided that the Plan does not have to pre-approve the feeding supplements, parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein, premix (B4189).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve Vertiflex. You say that this procedure is recommended when conservative
treatment has failed and as a safer alternative to laminectomy or spinal fusion. The Plan denied your request.
The Plan says the denial of authorization for this service is correct, because Vertiflex 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 pre-approve Vertiflex. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental, more research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the allograft and autograft services provided on May 12, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says separate charges are not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that for bundled procedures, payment for covered services is always bundled into payment for other services not specified.
In this case, the CPT Code Manual definition of code 20930 is allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure). The CPT Code Manual definition of 20936 is autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure). We find that CPT code 20930 and 20936 are bundled procedures. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the allograft and autograft services provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on April 21, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that you were given three dentists that were participating with your plan. You say that you were never told this provider was not participating. The Plan denied your request. The Plan says the claim reprocessed to pay for the comprehensive oral evaluation, prophylaxis and bitewing x-ray. The Plan says the panoramic x-ray remains denied as a non-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 panoramic x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography of the abdomen and pelvis; with
contrast (74177), the laboratory service (82565), and the low osmolar contrast material, 300-399 mg/ml iodine
concentration, per ml (Q9967) rendered by the OON provider on April 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 computed tomography of the abdomen and pelvis; with contrast (74177), the
laboratory service (82565), and the low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml
(Q9967) rendered by the OON provider on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injection provided on July 8, 
2021. 
 
You asked the Plan to waive the coinsurance for the Botox injection. You say that you paid a $35 copayment at 
the office visit and is not clear as to why there is an additional charge The Plan denied your request. The Plan 
says you have been asked to pay 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 20% of 
the total allowed amount for other in-network Medicare Part B drugs and their administration. 

You have been asked to pay $272.39 which is 20% of the allowed amount for the Botox injection. The allowed 
amount is $1,361.92. ($1,361.92 x 20% = $272.39). The Botox injection falls 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 the Botox injection provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (dental code D2740). 
 
You asked the Plan to pre-approve porcelain crown. You say that your crown was placed incorrectly and the 
tooth is now infected. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because you previously had a crown on February 25, 2021 so this benefit is exhausted. 
 
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 benefit for this service has been 
exhausted because you previously received a covered crown on February 25, 2021. Therefore, we decided that 
the Plan does not have to pre-approve a porcelain crown (dental code D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating provider on May 29, 2020, to June 2, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you would like full recoupment for this inpatient hospital stay. The Plan denied your request. The Plan says even though sepsis is documented in the medical record, supporting medical record documentation was not found within the record.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with A41.59, other gram-negative sepsis. 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 inpatient hospital care. Our reviewer says that enrollee was admitted to the hospital with presumed pyelonephritis with fever, tachycardia and tachypnea. Our physician reviewer found Sequential Organ Failure Assessment is a predictive mortality model, not guidelines to establish diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating provider on May 29, 2020, to June 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76700) provided June 1, 2021.

You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan
denied your request. The Plan says the code billed has a bundled relationship with another code billed and is
not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an ultrasound (76700) provided June 1, 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 January 12, 2021, to January 13, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that this should have only been an emergency room visit and you were only placed in a hospital room because there was no space available in the emergency room. 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 $360 copayment per day for days 1-5 for inpatient hospital services.

You have been asked to pay a $360 copayment for the inpatient hospital services. This copayment applies regardless of the reason for the inpatient admission. 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 January 12, 2021, to January 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 5, 2021,
by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the provider at issue has been treating you
for several years. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 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 psychotherapy services (90832) provided on April 5, 2021, by an
out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliances (E0673) provided on August 14, 2020.
You asked the Plan to pay for an intermittent limb compression device and pneumatic appliances. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliances (E0673) provided on August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on March 5, 2021.
You asked the Plan to pay for the pulpal debridement. You say that you contacted the Plan and were advised that the treating provider was in-network, and that you would be reimbursed for the procedure. The Plan denied your request. The Plan says this service 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. Therefore, we decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral device or appliance to reduce upper airway collapsibility (E0486) provided on June 16, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for an oral device. You say that the supplier at issue provided the item at a much lower price than estimates from a network supplier. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue is not enrolled in the Medicare program.
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 provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for an oral device or appliance to reduce upper airway collapsibility (E0486) provided on June 16, 2021, by a supplier not enrolled in the Medicare program.
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 March 5, 2021.
You asked the Plan to pay for occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers. 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 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 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 March 5, 2021.