Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the home health services you received from March 2, 2021, to March 26, 2021.
You asked the Plan to waive the copayments for the home health services. You say that you were never informed of this copayment. The Plan denied your request. The Plan says you were charged these copayments correctly.
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 $10 copayment for home health visits. You have been asked to pay a $10 copayment for each of the ten home health services you had, for a total of $100. This means that you have been asked to pay the correct amount based on your contract with the Plan. We decided that the Plan does not have to waive the copayments for the home health services you received from March 2, 2021, to March 26, 2021.
You asked the Plan to waive the copayments for the home health services. You say that you were never informed of this copayment. The Plan denied your request. The Plan says you were charged these copayments correctly.
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 $10 copayment for home health visits. You have been asked to pay a $10 copayment for each of the ten home health services you had, for a total of $100. This means that you have been asked to pay the correct amount based on your contract with the Plan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the filter removal surgery on March 22, 2021.
You asked the Plan to waive the copayment for the filter removal surgery. You say that you were told all claims related to the coronavirus are covered in full. You say the surgery was a result of having the coronavirus. The Plan denied your request. The Plan says you have been asked to pay 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 $250 copayment per visit for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $250 copayment for the filter removal surgery. The filter removal surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Please note, there is no provision in the contract which states a copayment will be waived due to the coronavirus. 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 filter removal surgery provided on March 22, 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 the SNF services. You say that you need treatment at the SNF as soon as possible. You say that a delay in SNF care could seriously jeopardize your life or health. The Plan denied your request. The Plan says the enrollee does not need daily skilled therapy services. The Plan says that the enrollee does not have any daily skilled nursing needs. The Plan says that the enrollee's needs can be met at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no skilled nursing needs and does not need skilled therapies on a daily basis in an inpatient setting at his current functional level. The enrollee's rehabilitation needs can be met at a lower intensity level. 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided October 15, 2019, to October 17, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that this diagnosis is supported by the medical records. The Plan denied your request. The Plan says the billed secondary diagnosis code is not supported in the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis code G92 defined as toxic encephalopathy. 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 pay for the inpatient hospital services. Our reviewer says that the billed secondary diagnosis code is not supported with the medical records submitted. Our physician reviewer found that the patient is an 80-year-old male who was admitted to the hospital with acute hyperglycemia related to steroid prescription. He was alert and oriented at the time of admission with Glasgow Coma Scale of 15 in the emergency department. Toxic encephalopathy was listed as a secondary diagnosis for the admission. Although confusion was listed as a subjective finding initially, it had resolved and there was no evidence suggestive of toxic encephalopathy at the time of admission or during the hospital stay. Therefore, the records provided do not sufficiently support the secondary diagnosis of G92 (toxic encephalopathy). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided October 15, 2019, to October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on April 14, 2021.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a colonoscopy screening and your benefits say that there is no copayment if you receive a surgical procedure during a colonoscopy screening. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for each covered diagnostic colonoscopy. The Plan contract also says that there are no cost-sharing charges for colorectal cancer screenings, which are covered every 24 months for high risk people.

The record shows that you had a colonoscopy screening on July 6, 2020. Therefore, the colonoscopy screening benefit was exhausted when you received a colonoscopy on April 14, 2021. Furthermore, the medical records show that you received a diagnostic colonoscopy on April 14, 2021. Therefore, you are responsible to pay the $325 copayment.

You have been asked to pay a $325 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the colorectal cancer screenings 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 diagnostic colonoscopy provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99153) provided on January 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting.
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6532.
You asked the Plan to pre-approve the compression stockings. You say that your legs and feet are swollen and you cannot walk due to the pain. You say that your doctor advised you that the compression stockings will stop
the swelling. You say that the requested stockings are medically necessary. The Plan denied your request. The Plan says there is no evidence that the enrollee has any open venous stasis ulcers or qualifying wounds requiring medically necessary debridement.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. You are documented to have scant edema bilaterally and there is no mention of ulceration. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6532.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception for a lower cost payment for a computed tomography (CT) scan of the thorax without contrast dye (71250), CT scan of the thorax with contrast dye (71260), and CT scan of the thorax with and without contrast dye (71270) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an exception for a lower cost payment for a CT scan of the thorax without contrast dye, CT scan of the thorax with contrast dye, and CT scan of the thorax with and without contrast dye to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an exception for a lower cost payment for a computed tomography (CT) scan of the thorax without contrast dye (71250), CT scan of the thorax with contrast dye (71260), and CT scan of the thorax with and without contrast dye (71270) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
Benefits for this drug 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 pre-approve scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that you really need your teeth cleaned. The
Plan denied your request. The Plan says scaling and root planing is covered once per quadrant in a 24-month
period. The Plan also says that the frequency limit has been reached.

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 dental
services when the services are medically necessary and reasonable.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the frequency limit has been reached. The
record shows that the Plan paid for scaling and root planing for the upper right and lower right quadrant that
you received on October 29, 2019. The record also shows that the Plan paid for scaling and root planing for the
upper left and lower left quadrants that you received on November 5, 2019.

These services were received less than 24 months prior to your request. Therefore, we decided that the Plan
does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating
provider on September 15, 2020, to September 23, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for
reconsideration of the DRG adjustment. The Plan denied your request. The Plan says the provider has reported
inpatient hospital services with the incorrect DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with A40.9, streptococcal sepsis, unspecified. 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 pay for inpatient hospital care. Our reviewer says that the
medical records did not support the change of the principal diagnosis code from A40.9 to L03.115. Our
physician reviewer found that the records received did not reflect any hemodynamic instability refractive to
initial fluid resuscitation, altered mental status, hypoxemia or abnormal bilirubin or platelet levels during the
encounter to substantiate a life-threatening acute organ dysfunction caused by a dysregulated response to
infection in order to support a diagnosis of sepsis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided by a non-participating provider on September 15, 2020, to September 23,
2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighteen skilled nursing home health visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says teaching and education should have occurred in the previous visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found you do not have documented skilled nursing needs, such as intravenous (IVs), complex wound care, new ostomy, new tube feeds). You are receiving wound care, which is relatively simple, provided in an easy-to-reach location and effective (wound improving). You have willing and able family and caregivers. As such, the requested ongoing homecare are not shown to be medically necessary or reasonable. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eighteen skilled nursing home health visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
October 17, 2021, forward. 
 
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the 
patient requires active treatment. 

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 mental health care. Our 
physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of October 17, 2021, forward and could have been treated in a lesser 
restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety. 
 
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 mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from October 17, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on April 17, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99307) provided on January 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not
payable. he 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 99307
has a bundled relationship with code 11721 and cannot be paid as billed. This code cannot be paid as a separate
line item. 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 services (99307) provided on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that the enrollee has a compression fracture of the lumbar spine which makes daily activities, such as getting up and down from the toilet difficult. 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 raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate , neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.