Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1851), provided on August 23, 2021.

You asked the Plan to pay for a knee brace. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the physician listed as the ordering physician adamantly denies ordering this brace 
and believes the brace was obtained through solicitation.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of a knee brace have 
not been met. Therefore, we decided that the Plan does not have to pay for a knee brace (L1851), provided on 
August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the triamcinolone acetonide injections provided on July 26, 2021.

You asked the Plan to waive the copayment for the triamcinolone acetonide injections. 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for two triamcinolone acetonide injections (total allowed amount $1,152 x 20% = $230.4). Triamcinolone acetonide injections 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 copayment for the triamcinolone acetonide injections provided on July 26, 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 family is not prepared to accept the enrollee home. You state they need to obtain equipment and have a ramp installed. The Plan denied your request. The Plan says the enrollee does not meet medical necessity for swing bed based on Medicare criteria for coverage guidelines.

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 the enrollee does qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. While the enrollee will be non-weight bearing on their lower extremities, the enrollee reasonably requires a period of transfer training, wheelchair (WC) training, occupational therapy (OT) compensatory training and durable medical equipment (DME) evaluations. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of sacrum and tailbone, minimum of 2 views (CPT)
code 72220-26 provided to the enrollee on July 27, 2021.

You asked the Plan to pay for the x-ray. You say that the services are supported. The Plan denied your request.
The Plan says the enrollee had professional interpretation of x-rays on July 27, 2021. The Plan states the
submitted documentation supports 1 (one) unit each of 72220-26 and 72110-26, which were previously
approved/paid. The Plan states there is no additional documentation supporting additional studies by this
provider which were billed and remain denied. The Plan states the reports submitted are duplicates of each
other.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

Review of the file shows the enrollee had professional interpretation of x-rays on July 27, 2021. The submitted
documentation supports 1 (one) unit each of 72220-26 and 72110-26, which were previously approved/paid.
There is no additional documentation supporting additional studies by this provider which were billed and
remain denied. The reports submitted are duplicates of each other. Based on this information, we decided that
Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have
to pay for the x-ray of sacrum and tailbone, minimum of 2 views (CPT) code 72220-26 provided to the enrollee
on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home visit (99348) debridement of nails
(11721) provided on August 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the home visit. You say that the services on this claim that were denied are not
part of any other services performed on this date or on any other date and should be considered separate and
distinct services. 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 established patient home visit (99348)
debridement of nails (11721) provided on August 10, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on July 7, 2021.

You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The claim submitted states that these services were denied due to the diagnosis code inconsistent with procedure billed. In addition, other documentation submitted states that this service was reported without an appropriate Z diagnosis. The documentation does not include a Medicare rule used to support that an appropriate Z diagnosis is required for this claim. No Local Coverage Determination or Local Coverage Article for the billing state of New York states that an appropriate Z diagnosis is required for the claim to be processed. Since the file is missing required documentation, this means that the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the ambulance services provided on July 7, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing
care in the home; per hour, (S9122) provided from April 13, 2021, to May 7, 2021.

You asked the Plan to pay for the home health services. You say that your surgeon advised these services
would be okay instead of a nursing home. You say that you needed care after your surgery. The Plan denied
your request. The Plan says the provider in this case does not participate with Medicare.

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 the home health aide or certified nurse
assistant, providing care in the home; per hour, (S9122) provided from April 13, 2021, to May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) provided on September 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a hospital outpatient clinic visit. You say that this provider regularly complies with all administrative requirements for payments. The Plan denied your request. The Plan says the referral was not authorized by the primary care physician (PCP). The Plan also says that this provider is not a network provider with the Plan and that they have also determined that these services are 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 a hospital outpatient clinic visit (G0463) provided on September 2, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 31, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that this was an emergency procedure to stop the pain from a cavity that reached a tooth root, requiring a root canal. The Plan denied your request. The Plan says the requested service exceeds the frequency limitation of your benefit Plan.

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 a limited oral evaluation once per plan year. 

We looked at the file and Medicare rules. The records show you received a limited oral evaluation on August 12, 2021; therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit rendered on April 27, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you want the Plan to pay for the bill because it was for emergency room visits. The Plan denied your request. The Plan says you were 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 $120 copayment for emergency care with the provider you visited. 

You have been asked to pay a $120 copayment for an emergency room visit. The record shows that the emergency room visit is covered. However, there is a copayment that is your responsibility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit rendered on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray provided on June 1, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were
not urgent, emergent, or approved in advance.
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 file shows that the enrollee was seen for knee pain, present for many years. The provider in this case is not
a network provider with the enrollee's 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 office visit and x-ray provided on June 1, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a PET-CT scan from the skull base to midthigh (78815) provided on September 7, 2021.

You asked the Plan to waive the copayment for a PET-CT scan. You say that the service at issue should be 
fully covered. The Plan denied your request. The Plan says the correct copayment was applied.

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 $250 
copayment for each day for Medicare-covered diagnostic radiology services that are not ultrasounds. 

You have been asked to pay a $250 copayment for a PET-CT scan. A PET-CT scan falls 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 
copayment for a PET-CT scan from the skull base to mid-thigh (78815) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia service rendered on August 24, 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 separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia service rendered on August 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 17,
2021, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the psychologist in question provides you
with services that your psychiatrist does not offer. The Plan denied your request. The Plan says rules for out-ofnetwork
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 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 psychotherapy services (90837) provided on
August 17, 2021, by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 16, 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 TENS therapy for chronic low back pain (CLBP) is covered when the beneficiary is enrolled in an approved clinical study meeting specific requirements. We looked at the file and Medicare rules. The file shows that the TENS therapy was not provided for CLBP. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on March 3, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made per Medicare.
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 99100 is Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. 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 of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on September 17, 2021.

You asked the Plan to pay for ultrasound 76705. You say that this was not a bundled service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 76705 has a procedure-to-procedure (PTP) edit of 1 with code 93976 so is not separately payable without an appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code ultrasound 76705 is a column II code to column I code 93976. 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 an abdominal ultrasound (76705) provided on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Aflibercept injection (J0178) provided on August 18, 2021.

You asked the Plan to waive the copayment for the Aflibercept injection. You say that you cannot afford the cost-sharing and was not aware that a coinsurance would apply to your injections after switching your plan. 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for the Aflibercept injection (allowed amount $1,832.82 x 20% = $366.56). Aflibercept injections 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 copayment for an Aflibercept injection (J0178) provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on April 20, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit limit for D0150 has already been 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. The Plan covers a 
comprehensive oral evaluation once every 36 months. 

We looked at the file, and Medicare rules. Evidence was provided to show that a comprehensive oral evaluation 
was provided on January 22, 2021. Based on this information, we decided that the Plan's rules for coverage of a 
comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on April 20, 2021.