Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on August 16, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for an electrocardiogram (EKG) and a specialist office visit provided on August 30, 2021.  

You asked the Plan to waive the copayments for an EKG and a specialist office visit. You say that the EKG copayment should be combined in the office visit copay. The Plan denied your request. The Plan says the proper copayments were applied for the services.  

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 $30 copayment for Medicare-covered non-radiological diagnostic services and a $40 copayment for services obtained from a specialist. For the EKG the total amount allowed was $15.98 which was less than the copayment amount of $30. 

Therefore, only $15.98 was charged for the copayment. The total amount of copayment for both services is $55.98 ($15.98 copayment + $40 copayment).  

You have been asked to pay a $55.98 copayment for an EKG and a specialist office visit. An EKG falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for an electrocardiogram (EKG) and a specialist office visit provided on August 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extremity study rendered on August 23, 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 claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 extremity study rendered on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99205) hospital discharge day management services (99238) unclassified drugs (J3490) provided from December 27, 2019, to January 29, 2020.  You asked the Plan to pay for the out of area emergency services. You say that these were emergency medical services that you received in Ireland. You spent 9 days in the hospital after being admitted through the emergency room. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the out of area emergency services was not filed until November 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99205) hospital discharge day management services (99238) unclassified drugs (J3490) provided from December 27, 2019, to January 29, 2020.
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 the IRF care. You say that acute inpatient rehabilitation care is critical for you to fully recover from your injuries. The Plan denied your request. The Plan says the submitted documentation does not support that you require the intensity of services provided at an acute inpatient rehabilitation facility as indicated by an intensive rehabilitation therapy program and close physician involvement.  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 the 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional days for inpatient psychiatric admission and services.  You asked the Plan to pre-approve additional days for inpatient psychiatric admission. You say that the requested additional days for inpatient psychiatric admission are medically necessary. The Plan denied your request. The Plan says the requested additional days for inpatient psychiatric admission do not meet criteria.  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 additional days for Inpatient Psychiatric admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not require inpatient mental health treatment beyond the dates in question as you are not a danger to yourself or others. It does not appear that active treatment was taking place beyond the date in question. You do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 3, 2022 forward and could be treated in a lesser restrictive setting as you are not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and is 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 additional days for Inpatient Psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve additional days for inpatient psychiatric admission and services.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ground mileage (A0425), non-emergency ambulance transport (A0428), and unlisted ambulance service (A0999) provided on December 21, 2020.  You asked the Plan to pay for the ground mileage, non-emergency ambulance transport, and unlisted ambulance service. You say that the enrollee required maximum assistance from your people due to the stretcher and could not transfer unassisted due to their requirement of oxygen. You also say that the enrollee was unable to sit in a wheelchair throughout the transport. The Plan denied your request. The Plan says that there was no authorization for the services rendered.  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 Plan did not provide a copy of the applicable medical records or 2020 Evidence of Coverage for this case. We asked for this information, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the ground mileage (A0425), non-emergency ambulance transport (A0428), and unlisted ambulance service (A0999) provided on December 21, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided April 21, 2021.

You asked the Plan to waive the copayment for the emergency ambulance services and ground mileage. You say that the copayment should be waived because you were in the hospital for multiple days. The Plan denied your request. The Plan says the copayment was not waived because you were not admitted as an inpatient. The copayment was applied 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 $200 copayment per trip for Medicare-covered ambulance benefits.

You have been asked to pay a $200 copayment for the emergency ambulance services and ground mileage. The emergency ambulance services and ground mileage fall within the Ambulance services benefit category. The Plan has verified that your time in the hospital was not associated with an inpatient admission. 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided April 21, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia for open procedures involving hip joint (01214) provided on September 4, 2021.  You asked the Plan to pay for the anesthesia. You say that this date of service is after the termination of the enrollee's Hospice period and should be paid. 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 enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on September 3, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for open procedures involving hip joint (01214) provided on September 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the second ambulance transportation trip (A0426) provided on August 11, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you were first taken to one hospital and then were transferred to a second hospital shortly after because the first hospital could not provide the services you needed. You say this copayment should be waived as this was out of your control and the same drivers and ambulance provided both trips. The Plan denied your request. The Plan says this claim was processed correctly, and your copayments were assessed in accordance with your contract. You are responsible for a $225 copayment for each Medicare-covered one-way trip by ground transportation. You received two trips on the date in question; therefore, two ambulance copayments apply.  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 $225 copayment for each Medicare-covered one-way ground transportation trip.   You have been asked to pay a $225 copayment for each of the ambulance transportation trips. 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 second ambulance transportation trip (A0426) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care rendered on June 30, 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 99309 (subsequent nursing facility care) and 99358 (prolonged evaluation and management services). Code 99309 is a column II code with a modifier indicator of 1 when billed with column I code 99358. Code 99309 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care rendered on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for podiatry services (11730, 11720, 10060) provided March 25, 2021.  You asked the Plan to pay for podiatry services. You say that the services were medically necessary. The Plan denied your request. The Plan says the codes billed share a bundled relationship with other codes billed and are not separately 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, we have confirmed that codes 11730, 11720, 10060 share bundled relationships with code 11042. 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 podiatry services (11730, 11720, 10060) provided March 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) of the pelvis (72192) and clinical decision support mechanism (G1004) provided on September 4, 2021.  You asked the Plan to pay for the pelvis CT and clinical decision support mechanism. You say that this date of service is after the termination of the enrollee's Hospice period and should be paid. 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 enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on September 3, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of the pelvis (72192) and clinical decision support mechanism (G1004) provided on September 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 27, 2021.  You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you think your dental insurance should have covered this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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.    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 cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-covered chiropractic services (99202 and 97035) provided on September 20, 2021.  You asked the Plan to pay for codes 99202 and 97035. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says codes 99202 and 97035 are not covered when billed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue, codes 99202 and 97035, are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services (99202 and 97035) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on August 5, 2021.  You asked the Plan to pay for the dental services. You say that you were having pain and discomfort where your bridge was. You say that they could not find anything wrong. You say that you went to a different dentist who did an x-ray and evaluation. You say that they referred you to an endodontist. You also say that the endodontist would not pull your tooth. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 plan years. The Plan says that complete series x-ray is covered once every 3 plan years. The Plan also says that these frequency limits have been exceeded.  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 and the evaluation and x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on February 18, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on August 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services rendered on September 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 a clinical psychologist must have a referral and consult
from the beneficiary's primary care physician (PCP).

We looked at the file and Medicare rules. There is no documentation of a referral and consult from the
enrollee's PCP. 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 psychotherapy services rendered
on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit rendered on July 12, 2021 to August 22, 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 procedure code 99509 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code 99509 (home visit for assistance with activities of daily living and personal care) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the home visit rendered on July 12, 2021 to August 22, 2021.