Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs daily physician monitoring, medication adjustment, and skilled nursing services. The Plan denied your request. The Plan says the enrollee has not completed the full course in the hospital.

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 physician reviewer found that in this case, the enrollee was admitted to the acute care hospital with aspiration failure due to pneumonia and suffered a stroke. The record indicates that he has a severely impaired mental status and cannot be weaned at this time. He has anemia and acute kidney injury. He 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.

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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Prolia injection provided on March 18, 2021.

You asked the Plan to waive the coinsurance for a Prolia injection. You say that you did not know there was a coinsurance and you are supposed to get this injection every six months. You also say if it will always cost this much, you will refuse it. 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 20% coinsurance for chemotherapy drugs. 

The record shows that the Plan has covered your Prolia injection; however, your coverage includes a cost sharing amount for which you are responsible. You have been asked to pay 20% of the allowed amount for a Prolia injection ($1,285.11 allowed amount x 20% coinsurance = $257.02).

Prolia injections fall within the 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 a Prolia injection provided on March 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided from
February 11, 2020, to February 26, 2020.

You asked the Plan to waive the copayment for emergency room services. You say that you went to the
emergency room due to the Coronavirus (Covid-19) You say you were told that you wouldn't have to pay the
copay. 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 $90
copayment for Emergency Care.

You have been asked to pay a $90 copayment for each visit for emergency room services. Emergency room
services fall within the Emergency Care benefit category. The records show the diagnoses for your visits were
not Coronavirus diagnoses. 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 emergency room services
provided from February 11, 2020, to February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on December
14, 2020.
You asked the Plan to waive the copayment for podiatry services. You say that you never received any
services, and the charges are fraudulent. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30
copayment for podiatry services.
The medical records show that you received podiatry services on December 14, 2020. Therefore, you are
responsible to pay $25.
You have been asked to pay $25, which is less than the $30 copayment for podiatry services. Podiatry services
fall within the podiatry 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
podiatry services provided on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have to waive the copayment for laboratory services provided from March 10, 2021, to March 26, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs and to waive the copayment for laboratory services. You say that you receive treatments every two weeks and have never owed a copayment before. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $10 copayment for lab services provided in an outpatient hospital facility. 

You received Medicare Part B drugs from March 10, 2021, to March 26, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $7,391 and 20% of that is $1,478.20. 

You received lab services on March 10, 2021. Therefore, you are responsible to pay the $10 copayment. 

You received lab services on March 24, 2021. Therefore, you are responsible to pay the $10 copayment. 

The total amount you owe is: $1,498.20. 

You have been asked to pay the total amount of $1,498.20 for Medicare Part B drugs and laboratory services. Medicare Part B drugs fall within the Medicare part B prescription drugs benefit category. Laboratory services fall 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 coinsurance for Medicare Part B drugs and does not have to waive the copayment for laboratory services provided from March 10, 2021, to March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83516, 83520, 86332, 86353, 86356, 86359,
88112, 88184, 88185, 88230, 88240, 88241, 88346, 88350) provided March 2, 2021.

You asked the Plan to pay for the lab tests. You say that the services were medically necessary. The Plan
denied your request. The Plan says the testing was of a screening nature and is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The lab testing in this appeal was requested solely for screening purposes. Medicare does not cover these tests
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (83516,
83520, 86332, 86353, 86356, 86359, 88112, 88184, 88185, 88230, 88240, 88241, 88346, 88350) provided
March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided February 3, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician.
The Plan must follow Medicare rules. Medicare rules say that when applying for a Medicare provider number, a CP must submit to the carrier a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, contingent upon the patient's consent, the CP will attempt to consult with the patient's attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality. We looked at the file and Medicare rules. In this case, the provider has not documented in the medical record the date the enrollee consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, the date and manner of notification to the physician. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for miscellaneous durable medical equipment (DME) supply
provided on May 20, 2021.

You asked the Plan to pay for miscellaneous DME supply, accessory, and/or service component of another
Healthcare Common Procedure Coding System (HCPCS) code. You say that the supply is separately
reimbursable. The Plan denied your request. The Plan says this supply with a Status indicator of Y is not paid
under the Outpatient Prospective Payment System.

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 A9900 has a Status Code of Y, non-implantable Durable Medical Equipment not paid
under the Outpatient Prospective Payment System (OPPS).

Based on this information, we decided that Medicare rules for coverage of miscellaneous DME supply,
accessory, and/or service component of another HCPCS code have not been met. Therefore, we decided that
the Plan does not have to pay for miscellaneous durable medical equipment (DME) supply provided on May
20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and x-ray provided on June 14, 201`.

You asked the Plan to pay for the extraction. You say that the dentist is part of the network. The Plan denied your request. The Plan says the x-ray will be reprocessed for payment and the extraction 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 extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction and x-ray provided on June 14, 201`.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (64999) provided July 27, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.

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 64999 is unlisted procedure of the nervous system.

We find that CPT code 64999 is not supported in the medical record. Specifically, the operative report does not
specifically detail what the unlisted procedure was. Based on this information, we decided that Medicare rules
for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to
pay for surgical services (64999) provided July 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 30 transportation trips (A0120).

You asked the Plan to pre-approve an additional 30 transportation trips. You say that you need additional trips to get to appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips 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 routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 30 transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator.
You asked the Plan to pre-approve osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748). You say that you had a single level fusion on September 8, 2021. The Plan denied your request. The Plan says Medicare guidance says a minimum of 9 months must have elapsed since the last surgery.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Also, you did not have a multilevel spinal fusion or previously failed fusion at the same site. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for infusions provided from January 26, 2021,
to February 5, 2021.

You asked the Plan to waive the coinsurance for infusions. 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 20%
coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a total of $981.80 in coinsurance, which is 20% of the allowed amount for
infusions.

Claim Number: Date of Service: Allowed Amount: 20% Coinsurance:

820210330651921 1/26/2021 $577.50 $115.50
820210330651925 1/27/2021 $577.50 $115.50
820210350463737 1/28/2021 $577.50 $115.50
820210350463668 1/29/2021 $577.50 $115.50
820210370197346 2/1/2021 $289.00 $57.80
820210400588304 2/2/2021 $577.50 $115.50
820210400588285 2/3/2021 $577.50 $115.50
820210400588926 2/4/2021 $577.50 $115.50
820210410430443 2/5/2021 $577.50 $115.50

Total: $4,909 $981.80

Infusions fall within the Medicare Part B Prescription Drugs benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for infusions provided from January 26, 2021, to February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripheral nerve block (64624).

You asked the Plan to pre-approve a peripheral nerve block. You say that this is necessary to manage the enrollee's pain after a fall. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

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 a peripheral nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this would be an experimental approach to the problem of knee pain following a total knee replacement. 

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 peripheral nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripheral nerve block (64624).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mammography services (77067, 77063) provided March 29, 2021.

You asked the Plan to pay for the mammography services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceed the allowed amount.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT codes 77067 & 77063 is 1. The MAI value for this code is 2. You billed 2 units each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the mammography services have not been met. Therefore, we decided that the Plan does not have to pay for mammography services (77067, 77063) provided March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 5, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on May 5, 2020. Therefore, you are responsible to pay $998.73, which is less than the 20% coinsurance amount.

You have been asked to pay the total coinsurance amount of $998.73 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for chiropractic manipulative treatment (98940) We decided that the Plan
does not have to pay for the spine x-ray (72100).

You asked the Plan to pay for chiropractic manipulative treatment (98940) and spine x-ray (72100). You say
that the treatment is not related to your auto accident and you should only have a copayment. The Plan says that
they cannot pay until they receive information for coordination of coverage.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.

The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not
directed the provider to send the bill to the primary insurer. X-rays provided by a chiropractor are not covered
by Medicare. Therefore, we decided that the Plan has to pay for manipulative treatment (98940) provided on
May 6, 2021, and May 11, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87640, and 87798) provided on June 15, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87541, 87581, 87640, and 87798) provided on June 15, 2020.