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

 We decided that the Plan does not have to pay for the home infusion therapy rendered on September 13, 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 covered.  The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on September 13, 2021.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the protective restoration (D2940) and application of desensitizing medicament (D9910) provided June 3, 2021.  You asked the Plan to provide additional payment for the protective restoration and application of desensitizing medicament. You say that you were told you would only have a small copayment and would not have had the services if you had known the provider was out-of-network. The Plan denied your request. The Plan says the protective restoration was processed correctly, and the application of desensitizing medicament is not a covered service.  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. The Plan covers the protective restorations with a $0 copayment. If you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment.  We looked at the file and Medicare rules. The Plan provided documentation showing that they covered the full allowed amount for the protective restorations. You are responsible for the difference between the allowed amount paid by the Plan and the total cost billed by the out-of-network provider. Though the Plan offers dental benefits in excess of Medicare coverage, the application of desensitizing medicament is not a covered service. Therefore, we decided that the Plan does not have to provide additional payment for the protective restoration (D2940) and application of desensitizing medicament (D9910) provided June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) provided July 14, 2021.  You asked the Plan to pay for the chiropractic service. You say that you saw this provider and they asked questions, examined you, but did not manipulate your spine because you had cracked ribs from an accident in January. Someone in the billing office or doctor's office coded this incorrectly. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.  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 pay for the outpatient office visit (99203) provided July 14, 2021.
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 clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says there is no advantage in moving the enrollee form the current acute care hospital to an LTACH.  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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 copayment for an office visit provided on August 3, 2021.  You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as it was an intro to medicare visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $5 copayment for Physician/Practitioner services, including doctor's office visits.        You have been asked to pay a $5 copayment for the office visit. The record indicates that that this was a follow up visit and not an intro to medicare visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic, without imaging guidance (62320) provided August 16, 2021.  You asked the Plan to pay for the injection services. You say that this treatment is a part of a comprehensive pain management program that has been implemented since all conservative measures, including more aggressive therapies such as surgical intervention has failed. The Plan denied your request. The Plan says this provider has not submitted any clinical records to support the medical necessity of the services.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. The records show that the Plan made multiple attempts to obtain additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic, without imaging guidance (62320) provided August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an office visit provided on September 21, 2021.  You asked the Plan to waive the deductible for the office visit. You say that the services should be covered. The Plan denied your request. The Plan says the deductible applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to Physician/Practitioner services, including doctor's office visits.            The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to Physician/Practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on September 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an Esophagogastroduodenoscopy (43239) provided on August 24, 2021.  You asked the Plan to waive the copayment for the Esophagogastroduodenoscopy. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 25% coinsurance for Outpatient hospital services.       You have been asked to pay a 25% coinsurance for an Esophagogastroduodenoscopy (allowed is $2128.36 x 25% = $ 532.09). Esophagogastroduodenoscopy's fall within the Outpatient hospital 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 an Esophagogastroduodenoscopy (43239) provided on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for debridement services provided on July 27, 2021.  You asked the Plan to waive the copayment for the debridement services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $150 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a $150 copayment for debridement services. Debridement services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 debridement services provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Duplex scan of extremity veins (93971) provided on September 5, 2021.  You asked the Plan to pay for code 93971. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93971 is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Duplex scan of extremity veins (93971) provided on September 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient hospital services provided December 1, 2020.  You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that outpatient hospital services are not supported. Specifically, the claim was not submitted with valid CPT / HCPCS codes for the services at issue. Based on this information, we decided that Medicare rules for coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a stair glide a stair glide provided on September 22, 2021.  You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide a stair glide provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive eye examination provided on  November 3, 2021.  You asked the Plan to pay for a comprehensive eye examination. You say that this exam should be covered since you believe your visit earlier in the year was not paid by the Plan. The Plan denied your request. The Plan says you received a routine eye exam, comprehensive (92004) on June 07, 2021. Therefore, you have exceeded the benefit limit of 1 routine eye exam per calendar year. The Plan also says with regard to date of service June 7, 2021 the routine eye exam, comprehensive (92004) was processed and paid by the Plan.  Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that you received a routine eye exam, comprehensive on June 07, 2021. Therefore, you have exceeded the benefit limit of 1 routine eye exam per calendar year. Based on this information, we decided that the Plan's rules for coverage of a comprehensive eye examination have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive eye examination provided on November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomographic angiography of the chest (71275) provided on September 3, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).   You have been asked to pay $160 copayment for the Medicare-covered radiological diagnostic service provided. 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 computed tomographic angiography of the chest (71275) provided on September 3, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that 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/she 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injections (62320) provided on October 25, 2021.  You asked the Plan to pay for code 62320. 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.  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 to verify if the services were billed correctly per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the injections (62320) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for targeted case management provided on August 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the targeted case management. You say that you are appealing this denial.   The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for targeted case management provided on August 29, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Fluoroscopic guidance for central venous access device placement, replacement, or removal (77001) provided on September 16, 2021.  You asked the Plan to pay for code 77001. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77001 is a column II code to column I code 77012. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Fluoroscopic guidance for central venous access device placement, replacement, or removal (77001) provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation device (TENS) (E0730) and DME delivery, set up, and/or dispensing service (A9901) provided on June 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the medical equipment. You say that this claim was denied because it lacked records, but you faxed all records and you were told to submit a claim appeal to get this claim processed. Please reprocess the claim accordingly. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation device (TENS) (E0730) and DME delivery, set up, and/or dispensing service (A9901) provided on June 29, 2021 by an out-of-network (OON) provider.