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

 We decided that the Plan does not have to pay for the periapical x-ray (D0220) and extraction (D7140) provided on September 17, 2021.  You asked the Plan to pay for the dental services. You say that you have an unused pre-treatment estimate for a crown that is not needed. You also say that these services should be covered. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500. The Plan says that the annual maximum benefit has been exhausted prior to the date of service. The Plan also says that a pre-treatment estimate does not count towards any paid benefit amount.  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.   Date of Service Plan Paid 1/22/2021 $255.50 5/24/2021 $722.50 6/28/2021 $120 7/28/2021 $235 8/25/2021 $167 TOTAL: $1,500  The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) and extraction (D7140) provided on September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on January 17, 2021,
through January 24, 2021 and billed with diagnosis codes A41.9 and G92.
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration
because the documentation submitted supports the diagnosis codes billed. The Plan denied your request. The
Plan says the documentation does not support the primary and secondary diagnosis codes.
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 A41.9 and G92. 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 review has determined
that the documentation did not support the billing of diagnosis codes A41.9 and G92. Our physician reviewer
found the reviewed documentation indicates that the member was admitted for cellulitis and non-healed
ulceration of the left foot and was found to have osteomyelitis (not associated with diabetes mellitis). Infectious
Disease (ID) consulted on the patient and noted "sepsis" under a "Patient Identification" heading, although
notes from ID only addressed osteomyelitis, severe cellulitis of left medial forefoot, and septic 1st
metatarsophalangeal joint. A discussion was held between the infectious disease physician and the patient, as
the patient was noted to be ambivalent whether to proceed with amputation vs IV antibiotics as treatment. ID
advised the patient that the chance of recurrence was high with choice for IV antibiotics as an outpatient, and
that there was a risk that infection could spread more proximally requiring extensive amputation in the future,
and "rarely even sepsis and death". Sepsis was not a diagnosis noted in the discharge summary.
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 on January 17, 2021, through January 24, 2021 and billed with
diagnosis codes A41.9 and G92.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the socket insert (L5679) and suspension sleeve (L5685), provided on August 28, 2021.

You asked the Plan to pay for the socket insert and suspension sleeve. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has been billed with an inappropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the socket insert, and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the socket insert (L5679) and suspension sleeve (L5685), provided on August 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for critical care provided on
July 30, 2021.

You asked the Plan to pay for physician's services for critical care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 physician's services for critical care provided on
July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a standard wheelchair provided from
August 17, 2021, to October 17, 2021.
You asked the Plan to waive the coinsurance for the wheelchair. You say that the wheelchair is paid off and
you should not be getting billed for it. The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for durable medical equipment (DME), oxygen equipment, and related supplies.
Item Allowed Amount 20% Coinsurance
Wheelchair - August 17, 2021 $44.04 $8.80
Wheelchair - September 17, 2021 $44.04 $8.80
Wheelchair - October 17, 2021 $44.04 $8.80
Total: $26.40
You have been asked to pay $26.40, which is 20% of the allowed amount for the wheelchair. The wheelchair
falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a standard wheelchair provided from August 17, 2021, to October
17, 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 enrollee lives alone and is not independent.
You say that the enrollee's arm is broken, and she cannot help herself. The Plan denied your request. The Plan
says the guidelines for coverage have not been met.
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 there is no documentation that the
patient requires skilled nursing services. There is documentation supporting the need for skilled therapy
services, but they are not required on a daily basis. The enrollee does not require the services on an inpatient
basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term
care facility on a part time basis appear appropriate in this case.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH
would provide no additional services. With more time in the current setting, clinical stability can be ensured
such that the appropriate lower level of care can be determined.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be somewhat unstable but is without complex care needs and
requires only short-term additional acute care services that can safely be administered at the current facility.
The enrollee does not require services at the LTACH that are not already available and covered at the current
facility. Transfer to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer
to a lower level of care may be considered when treatment has completed and the enrollee is more stable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided by a network physician on September 17, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you were told this visit was included in your surgery and that you should not have a copayment. 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 $35 copayment for each in-person specialist visit.

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure.

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 office visit provided by a network physician on September 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the subcutaneous tissue debridement (11042) provided on August 25, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.     You have been asked to pay $343.31 for the Medicare-covered surgery provided at an outpatient hospital.  This is the Plan's allowed amount for this service which is less than the applicable copayment. 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 subcutaneous tissue debridement (11042) provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), limited oral evaluation - problem focused (D0140), bitewing - single radiographic image (D0270), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and pulp vitality tests (D0460) provided October 27, 2021.  

You asked the Plan to pay for the intraoral x-rays, limited oral exam, bitewing x-ray, cone beam CT scan and pulp vitality tests. You say that the services are expensive, and you expected the Plan to pay for part of the cost. The Plan denied your request. The Plan says the services have processed correctly.  

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 one intraoral x-ray and one bitewing x-ray per calendar year. This benefit also includes two exam per calendar year.  

We looked at the file and Medicare rules. The Plan provided documentation showing that they previously covered a periodic oral exam and bitewing x-rays on March 2, 2021, and a periodic oral exam and intraoral x-rays September 16, 2021. Based on this information, we decided that the Plan's rules for coverage of the intraoral x-rays, limited oral exam, bitewing x-ray, cone beam CT scan and pulp vitality tests have not been met. Based on this information we determined that you have exceeded the frequency limits for the intraoral x-rays, limited oral exam and bitewing x-rays. Though the Plan offers dental benefits in excess of Medicare coverage, the cone beam CT scan and pulp vitality tests are not among those covered services. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), limited oral evaluation - problem focused (D0140), bitewing - single radiographic image (D0270), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and pulp vitality tests (D0460) provided October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the ostomy supplies. The Plan does not have to fully waive the coinsurance for the ostomy supplies.

You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you never had to pay for the supplies before. The Plan says that the correct coinsurance was applied.

You have been asked to pay $213.72 for the ostomy supplies. Based on the Plan contract, however, you cannot be asked to pay more than $181.31, which is 20% of the allowed amount for the ostomy supplies. Therefore, we decided that the Plan has to reduce the coinsurance for the ostomy supplies provided on December 30, 2020.

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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for an eye refraction provided on October 19, 2021.  You asked the Plan to reimburse you for an eye refraction. The Plan denied your request. The Plan says there is no coverage for a routine vision exam including refraction with any provider that does not participate with the Plan's vision provider.  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, Medicare rules and the Plan's rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. The contract with your Plan says there is no coverage for a routine vision exam including refraction with any provider that does not participate with the Plan's vision provider. Therefore, we decided that the Plan does not have to reimburse you for an eye refraction provided on October 19, 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 the records do not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting. The Plan says that the enrollee's needs are custodial and are not a covered benefit.  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 records do not support that the enrollee requires skilled nursing or skilled therapy services. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting.  Custodial care in a long-term care facility appears appropriate in this case.  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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) provided on September 12, 2021.

You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says and edit exists between CPT codes 70450 and 70496.

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 70450 is a column II code to column I code 70596. 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 computed tomography (CT) of the head or brain (70450) provided on September 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan
provided on September 9, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that the service was never completed so
there should not be a copayment charged. The Plan denied your request. The Plan says records provided by the
provider show the service was completed with detail findings of the imaging. Therefore, the proper 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 Medicare-covered advanced imaging service.

You have been asked to pay a $250 copayment for a CT scan. The CT scan falls within 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 computerized tomography (CT) scan provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on August 30, 2021.

You asked the Plan to pay for the office visit. You say that this visit should not have been denied. The Plan denied your request. The Plan says that the code has a professional/technical component indicator of 3.

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 99213 is office or other outpatient visit for the evaluation and management of an established patient. We find that CPT code 99213 has a professional/technical component (PC/TC) indicator of 0. This indicator identifies codes that describe physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Therefore, we decided that the Plan has to pay for the office visit provided on August 30, 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.