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

 We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on October 29, 2020.  You asked the Plan to pay for the ophthalmological services, medical examination. The Plan denied your request. The Plan says the Plan needs an Explanation of Benefits from the primary insurance carrier.  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 met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the ophthalmological services, medical examination until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services, medical examination provided on October 29, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on June 19, 2020.
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original
Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or
suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the
enrollee's hospice election until the first day of the month after the hospice election has been revoked or
terminated.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness.
The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for ambulance services provided on June 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve shoulder arthroscopy (29827, 29828, 29824, 29826).  You asked the Plan to pre-approve shoulder arthroscopy. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  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 shoulder arthroscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation to indicate any other treatments having been tried for at least 3 months. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder arthroscopy (29827, 29828, 29824, 29826).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted small intestine procedure (44799) provided on March 15, 2021.  You asked the Plan to pay for the unlisted small intestine procedure (44799). You say that there is no designated code for the service billed. You say that medical records are attached for review and the denial should be waived. The Plan denied your request. The Plan says this procedure is considered inclusive to CPT code 44650 and is not payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 44799 is unlisted procedure, small intestine.    We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the unlisted small intestine procedure (44799). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that if closure of a fistula requires excision of a portion of an organ into which the fistula passes, excision of that tissue shall not be reported separately. Therefore, the documentation does not support the reporting of CPT 44799 with CPT 44650.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the unlisted small intestine procedure (44799) have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted small intestine procedure (44799) provided on March 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided July 13, 2021.  You asked the Plan to pay for the core buildup. You say that you were told this provider was in-network. The Plan denied your request. The Plan says the claims from this date of service were re-processed as in-network however the core buildup is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on October 7, 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.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (TDaP) vaccine rendered on October 7, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a consultation and electrocardiogram provided on September 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the consultation and electrocardiogram. You say that the services were unforeseen while you were visiting your daughter out-of-state. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the consultation and electrocardiogram provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve inpatient admission for the treatment of migraine headaches.  You asked the Plan to pre-approve inpatient admission for the treatment of migraine headaches. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 inpatient admission for the treatment of migraine headaches. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found the proposed course of treatment is going to involve intravenous (IV) Dihydroergotamine, anti-emetics, IV steroids and possibly anti-psychotics. The duration of hospitalization is expected to be for more than 2 midnights. In such a setting/context, this request meets the Medicare definition of medical necessity.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for the treatment of migraine headaches have been met. Therefore, we decided that the Plan has to pre-approve inpatient admission for the treatment of migraine headaches.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99204) provided on September 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that the services were an unforeseen event as you were informed that the biopsy from a visit weeks ago was Melanoma while you were staying with your daughter in a different state. The Plan denied your request. The Plan says they do not believe that the out-of-network care you received was urgent or emergent and required a medical visit before you could have safely returned to the surgical oncologist who your doctor referred you to.   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 specialist office visit (99204) provided on September 17, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no prescription for insulin treatment therapy.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 12, 2021, to October 14, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not receive a detailed list of what was being charged for the copayment. The Plan denied your request. The Plan says the appropriate 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 $260 copayment for In-Network Inpatient Care per day for days 1 to 7 and the day before you are discharged is your last inpatient day. For a stay of 2 days the charge would be $520 ($260 inpatient stay a day x 2 days).  You have been asked to pay a $520 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the Inpatient hospital care 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 inpatient hospital stay provided from October 12, 2021, to October 14, 2021.   Your complaint about not receiving a detailed bill from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care services (99223) provided on June 1, 2021.  You asked the Plan to pay for the initial hospital care services. You say that this claim should be reprocessed as the enrollee was seen by two providers and billed these procedures separately as such. The Plan denied your request. The Plan says this claim has processed correctly.  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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  We looked at the file and Medicare rules. In this case, we have confirmed that the Plan has paid one unit of 99223. A second unit of 99223 is not warranted as both claims have been filed as being rendered by the same provider. There is no evidence that a provider in a different specialty rendered the second billed unit of 99223. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services (99223) provided on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coveraue inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99204) provided on September 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says the request is for services by a non-contracted provider. The Plan also says there is no referral letter from an in-network physician and the services were not medically necessary.  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 specialist office visit (99204) provided on September 29, 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 an eye refraction provided on October 21, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by your Plan if performed by a participating provider and performed as a routine screening.  Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.   We looked at the file, the Medicare rules and the Plans rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. The Plan only covers refractions if performed by a participating provider and performed as a routine screening. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on June 7, 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 payment is included in the global surgical package.  The Plan must follow Medicare rules. The rules say that post-operative services are included in the global surgical package.  We looked at the file and Medicare rules. Billed procedure codes 99213 (office visit) and 68761 (closure of the lacrimal punctum; by plug, each) were billed within 90 days of major global procedure 66984 (cataract removal). These services are related to the original procedure and payment is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on April 5, 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 all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 5, 2021.