Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for physical therapy provided by a participating provider
on June 3, 2021, to July 12, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you would like a refund for
these sessions. The Plan denied your request. The Plan says that the correct copayments have been applied.
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 has failed to provide a 2021 Evidence of Coverage. Therefore, we
decided that the Plan has to waive the copayment for physical therapy provided by a participating provider on
June 3, 2021, to July 12, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (00104) provided on August 8, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was billed with an incorrect place of service code.

The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.

We find that CPT code 00104 is not supported in the medical record. Specifically, this claim was billed with the outpatient place of service code. The record shows that the member was registered inpatient on the billed date of service. This claim has not been billed with the appropriate place of service code. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00104) provided on August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Percepta testing provided on August 25, 2021.
You asked the Plan to pay for the services provided. You say that the test reduces the need for further invasive
diagnostic procedures. The Plan denied your request. The Plan says the test is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that Percepta testing is only covered under certain
medical indications.
We looked at the file and Medicare rules. In this case, there were insufficient medical records to show that the
coverage criteria were met. There is no record of the enrollee's smoking history, bronchoscopy or other testing
that were provided. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pay for the Percepta testing provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax from services received from August 27, 2021, to
August 28, 2021.
You asked the Plan to pay for sales tax. You say that the services should be covered due to your medical
condition. The Plan denied your request. The Plan says sales tax is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that sales tax is not a covered benefit.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of sales tax have not been met. Specifically, sales tax is not covered by Medicare or the Plan.
Therefore, we decided that the Plan does not have to pay for sales tax from services received from August 27,
2021, to August 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on August 10, 2021.

You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct code.

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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 

We find that CPT code G0482 is not supported in the medical record. Specifically, the records document only 8 drug classes. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the panoramic x-ray (D0330), and to
pay for the extraction (D7210) provided on September 10, 2021 by the out of network dentist.
You asked the Plan to pay an additional amount for the dental services. You say that you would like to appeal
the denial of payment for this claim. You also say that you received an x-ray that you believe is covered. The
Plan denied your request. The Plan says out of network providers may bill you for any amount greater than
what the Plan pays. The Plan says that The Plan also says that extraction is not listed as a covered service.
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 panoramic x-ray is listed as
covered, out of network providers may bill you for any amount greater than what the Plan pays. Additionally,
the extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have
to pay an additional amount for the panoramic x-ray (D0330), and to pay for the extraction (D7210) provided
on September 10, 2021 by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) and retainer crown
(D6750) provided on December 29, 2020.
You asked the Plan to pay for the resin-based composite and retainer crown. You say that on February 4, 2021
you had received your bridge and were not made aware of any insurance denials by the dentist's office. The
Plan denied your request. The Plan says your annual dental benefit maximum has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental
benefit maximum, less the cost-sharing you pay. The contract says that after your annual maximum benefit
maximum has been met, you are responsible for the full charges of any additional dental services. The record
shows that you met the annual maximum benefit while processing this claim for the December 29, 2020 date of
service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the resin-based composite (D2392) and retainer crown (D6750) provided on December 29,
2020.
Your complaint about having less of a tooth and your bridge being worse than before 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on October 19, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were provided in good faith. The
Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The file shows that the enrollee was seen for the management of chronic symptoms and medication
management. The provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the home visit provided on October 19, 2021, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a standard wheelchair (K0001), a folding wheeled walker (E0143), and a wheelchair seat cushion (E2601) provided on December 24, 2020, by an online retailer.  You asked the Plan to pay for a standard wheelchair, a folding wheeled walker, and a wheelchair seat cushion. You say that the medical equipment at issue was a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the items at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a standard wheelchair (K0001), a folding wheeled walker (E0143), and a wheelchair seat cushion (E2601) provided on December 24, 2020, by an online retailer.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided to the enrollee on May 11, 2021.  You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported.  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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older."  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 . Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure report was reviewed, and no documentation was found in the report to support an independent trained observer assisted in the monitoring of the enrollee's level of consciousness and physiological status. Per the CPT 99152 code description this criteria would be documented in the report to confirm procedure has been provided.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided to the enrollee on May 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional home health skilled nursing, occupational therapy, and speech therapy services.  You asked the Plan to pre-approve the requested home health services. You say that it is felt that ongoing home health services are required for the enrollee's condition. The Plan denied your request. The Plan says the requested services are custodial in nature.  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 requested home health services. Our reviewer says that the records provided do not support the medical necessity of the requested home health services. Our physician reviewer found the enrollee is a male with Parkinson's disease, congestive heart failure, and a chronic Foley catheter requesting home health care services. He has been receiving home health care services since at least November 2021. There is no indication he has had a recent illness or injury. He uses a wheelchair for mobility and tolerates an oral diet. He requires a caregiver for daily self-care tasks.  In this case, the documentation does not support that the member requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.  The requested home health services are not medically necessary.  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 requested home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled nursing, occupational therapy, and speech therapy services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on October 6, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that Medicare pays 100% for lab work to the provider. The Plan denied your request. The Plan says the proper copayment was applied and a lower rate was negotiated with the provider's network.  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 $50 copayment for Outpatient Hospital Lab Services. After the negotiated amount of $36.72 for the copayment that is less than the $50 normal copayment amount for laboratory services.    You have been asked to pay a $36.72 copayment for the laboratory services. Laboratory services falls within the Outpatient hospital observation 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 laboratory services provided on October 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prostate cancer screening (G0103) provided on September 1, 2021.  You asked the Plan to pay for the cancer screening. You say that this service is listed as a covered in your plan guide. You say that there is no indication of how often the screening can occur. You say that you are considered high-risk. You also say that you have been getting this test done every 6 months for approximately 20 years and it has always been covered. The Plan denied your request. The Plan says coverage of a prostate screening test is limited to once every 12 months. The Plan also says that the frequency limit has been exceeded.  The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cancer screening test have not been met. Specifically, the file shows that the frequency limit has been exceeded. The file shows that the Plan paid for a prostate screening test that you received on March 4, 2021, less than 12 months prior. Therefore, we decided that the Plan does not have to pay for the prostate cancer screening (G0103) provided on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided June 30, 2021, to July 17, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that rehabilitation services should have a $0 copayment. The Plan denied your request. The Plan says 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 $500 copayment for each Medicare-covered hospital stay.   You have been asked to pay a $500 copayment for the inpatient rehabilitation services. The inpatient rehabilitation services fall 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 the inpatient rehabilitation services provided June 30, 2021, to July 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the SNF services.  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 you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 the Skilled Nursing Facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 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 the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 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 SNF services. You say that you need to get strong again. The Plan denied your request. The Plan says your rehabilitation goals can be met with intermittent skilled services.  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 physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you are at a supervision to moderate assist level for functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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.