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

We decided that the Plan does not have to pay for the palliative treatment of dental pain, minor procedure (D9110) provided on October 15, 2021.

You asked the Plan to pay for the dental service. You say that you were in pain. You also say that you could not eat. The Plan denied your request. The Plan says palliative treatment is not listed as 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the palliative treatment not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative treatment of dental pain, minor procedure (D9110) provided on October 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on September 20, 2021.  

You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met.

 Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the services the enrollee requires can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on October 25, 2021.

You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on November 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee out of medical necessity. The Plan denied your request. The Plan says the provider is an out-of-network provider, and the referring physician is a non-participating provider. Also, the services were not urgent or emergent.   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 an office visit provided on November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 5, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on August 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen tank (E1392).  You asked the Plan to pre-approve a portable oxygen tank. You say that your current device is heavy and difficult to use. The Plan denied your request. The Plan says duplicate or redundant durable medical equipment such as oxygen device when the second item performs the same function as the one currently provided is not covered.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that you have a standard lightweight oxygen tank. a standard lightweight oxygen tank serves the same purpose as a portable oxygen tank. Specifically, you are already being provided the most appropriate equipment that meets your needs. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen tank (E1392).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on September 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that the referring physician is an in-network provider who ordered the services. The Plan denied your request. The Plan says the referring physician is a non-participating provider who ordered the services from a non-participating provider. The services were determined not to be urgent or emergent.  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 laboratory services provided on September 22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 13, 2021.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate place of service code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code G0483 is not supported in the record. Specifically, this claim was billed with the laboratory place of service code while the record indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to hold you harmless for the Evenity injections. We decided that the Plan does not have to waive the copayment for the specialist services.  You asked the Plan to waive the copayment and pay for these services. You say that you disagree with the denial. The Plan says that the claim was processed correctly.  We decided that the Plan has to hold you harmless for the Evenity injections.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You received Evenity injections from a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services are considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the Evenity injections rendered from August 3, 2021 to September 29, 2021.  We also decided that the Plan does not have to waive the copayment for the specialist services.  Review of the file shows that you received specialist services from August 3, 2021 to September 29, 2021. You have been asked to pay a $45 copayment per date of service for these services. These services fall within the specialist 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 the specialist services rendered from August 3, 2021 to September 29, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 14, 2021, to June 23, 2021.

You asked the Plan to waive the copayment for the inpatient hospital care. 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 $403 copayment per day for days 1-5 of Inpatient hospital care.

You have been asked to pay a $2,015 copayment for days 5 of inpatient hospital care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 14, 2021, to June 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says SNF care is not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs.  The application of cream to her buttocks is not considered skilled or complex.  The enrollee did not have documented skilled therapy needs.  The enrollee had already received a month of SNF care at another facility.  Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs, custodial and intermittent, could, as a practical matter, be provided at a lower level of care.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) segmental pneumatic appliance (E0673) provided July 27, 2021.  You asked the Plan to pay for a pneumatic compression device and appliance. You say that these services are not paid to you by the facility and payment for items used should not be included with payment to the facility, as you bill charges separately for services provided. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) segmental pneumatic appliance (E0673) provided July 27, 2021.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for SNF services. We decided that the Plan does not have to waive all of the copayments for SNF services rendered from February 1, 2021, to February 28, 2021.

You asked the Plan to waive part of the copayments for SNF services. You say that you were told that all copayments were zero from your Plan since it was a special needs and extra help. You also say that you are not able to make these payments if denied. The Plan says that you were charged the correct cost sharing amount.

We decided that the Plan has to reduce the copayment for SNF services.

The Plan says that you must pay a $1,975 copayment for SNF services. Based on your contract with the Plan, however, you can only be asked to pay $1,288 for days 21-27 ($184 copayment/day x 7 days = $1,288.) You are not charged a copayment for the discharge day. Therefore, we decided that the Plan has to reduce the copayment for SNF services from $1,975 to $1,288.

We also decided that the Plan does not have to waive the entire copayment for SNF services.

Medicare rules say that 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 says that you must pay a $0 copayment per day for days 1 - 20, and a $184 copayment per day for days 21-100 for SNF care. Your total copayment is $1,288 ($184 copayment/day x 7 days= $1,288). Therefore, we decided that the Plan does not have to waive the entire copayment for the SNF services provided from February 1, 2021, through February 28, 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from August 20, 2021, through September 18, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says by August 20, 2021, the enrollee no longer needed daily skilled care from either a nurse or a therapist. Continued assistance with routine daily activities could be safely provided at the custodial level of care as it had been before.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.        We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services provided from August 20, 2021, through September 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording (93228) provided September 2, 2021.  You asked the Plan to pay for the EKG Holter monitoring service. You say that you were in emergency for supraventricular tachycardia (SVT) which lasted for hours. The EKG Holter monitoring service was ordered to try to capture an arrhythmia that might have initiated the SVT. The Plan denied your request. The Plan says this service is not covered by Medicare, and therefore is not covered by the Plan.  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 93228 is external mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days.  We find that CPT code 93228 is not supported in the medical record. Specifically, CMS designates 93228 as not paid by Medicare when submitted on outpatient claims. Outpatient cardiac telemetry should not be reported for patients in hospitals, emergency rooms, skilled nursing facilities or other specialized facilities and, if reported as such, will be denied. Based on this information, we decided that Medicare rules for coverage of the EKG Holter monitoring service have not been met. Therefore, we decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording (93228) provided September 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95822) provided on February 16, 2021.  

You asked the Plan to pay for the EEG. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT code 95822 and 51785  

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 95822 is a column II code to column I code 51785. 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 Electroencephalogram (EEG) (95822) provided on February 16, 2021.