Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to adjust the coinsurance for the tubing (A7037), cushion (A7032), chinstrap
(A7036), disposable filter (A7038), and the non-disposable filter (A7039) provided. We decided that the Plan
does not have to adjust the coinsurance for the headgear (A7035) and the nasal interface (A7034) provided.
You asked the Plan to adjust the coinsurance for the durable medical equipment provided. You say that you are
requesting a reconsideration of the Plan's denial for payment. The Plan says that the coinsurance has been
applied correctly to the items provided.
We decided that the Plan has to adjust the coinsurance from $99.06 to $39.63 for the tubing (A7037),
cushion (A7032), chinstrap (A7036), disposable filter (A7038), and the non-disposable filter (A7039)
provided on March 6, 2021. The Plan Explanation of Benefits (EOB) Statement indicates your responsibility
as $99.06 (Plan allowed amount of $198.13 x 50% coinsurance) for the durable medical equipment provided.
However, the Plan contract states that a 20% coinsurance applies to durable medical equipment and related
supplies provided. Therefore, we decided that the Plan has to adjust the coinsurance from $99.06 to $39.63 for
the tubing (A7037), cushion (A7032), chinstrap (A7036), disposable filter (A7038), and the non-disposable
filter (A7039) provided on March 6, 2021.
We also decided that the Plan does not have to adjust the coinsurance for the headgear (A7035) and the
nasal interface (A7034) provided on March 6, 2021. The Plan Explanation of Benefits (EOB) Statement
indicates your responsibility as $18.89 (Plan allowed amount of $94.45 x 20% coinsurance) for the durable
medical equipment provided. Your contract with the Plan states that a 20% coinsurance applies to durable
medical equipment and related supplies provided. Therefore, we decided that the Plan does not have to adjust
the coinsurance for the headgear (A7035) and the nasal interface (A7034) provided on March 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compressor, segmental home model with
calibrated gradient pressure (CPT code E0652) and segmental pneumatic appliance for use with pneumatic
compressor (CPT code E0669).
You asked the Plan to pre-approve the DME. You say that you use an ACE bandage every day and your legs
keep getting bigger. You state you have been sitting up in a chair for months. You state you are supposed to
urinate the excess liquid out, but it has not happened. You state the device could reduce the edema and save
your life. The Plan denied your request. The Plan says there is no indication in the medical records received
that you have lymphedema that extends to the trunk of your body or chest. The Plan states that in addition, the
October 7, 2021, medial record shows that you have chronic leg edema which has significantly decreased since
your previous visit. The Plan states the medical records also show that you are being treated with spiral ace
wraps and diuretics (medication to help rid body of water) and there are no signs of leg sores.
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 DME. Our physician reviewer
found the reviewed documentation indicates that you have lymphedema (swelling) of both legs. There is no
indication in the medical records received that you have lymphedema that extends to the trunk of your body or
chest. In addition, the October 7, 2021, medical record from the provider state that you have chronic leg edema
which has significantly decreased since your previous visit. The medical records also show that you are being
treated with spiral ace wraps and diuretics and there are no signs of leg sores. The review has determined that
the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve the pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code
E0652) and segmental pneumatic appliance for use with pneumatic compressor (CPT code E0669).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair cushion.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any durable medical equipment (DME) item to a beneficiary. 

We looked at the file and Medicare rules. There is no valid physician order for the DME. There is also no claim for a wheelchair for this enrollee. 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 pre-approve a wheelchair cushion.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient eye surgery you had at an ambulatory surgery center on May 18, 2021.
You asked the Plan to waive the cost sharing for the outpatient surgery. You say that you were told that the deductible did not apply to this surgery. The Plan denied your request. The Plan says you were charged this cost sharing 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 says that you have an $800 deductible that applies to outpatient surgery. After the deductible is met, your contract says that you must pay a $450 copayment for outpatient surgery at an ambulatory surgery center. You have been asked to pay the applicable $800 deductible and, once that is met, a $450 copayment for the outpatient surgery. The Evidence of Coverage clearly states that this deductible applies to outpatient surgery. You had not met this deductible at the time of the surgery. Your contract also clearly states that once you meet this deductible, you are responsible for the applicable $450 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 cost sharing for the outpatient eye surgery you had at an ambulatory surgery center on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal maxillary extraction and anesthesia provided on
February 3, 2021.
You asked the Plan to pay for the dental services. You say that you realize that this surgery is elective. You say
that it is the difference between chewing food or not. You also say that you would appreciate any help with this
bill. The Plan denied your request. The Plan says the services you received exceed the Plan's dental policy.
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare.
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction and anesthesia are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the nasal
maxillary extraction and anesthesia provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 20, 2021.

You asked the Plan to pay for the dental services. You say that you feel that this claim should be paid in full as the services were preventive. You also say that you have had coverage in the past where all preventive services were covered at no cost to you. The Plan denied your request. The Plan says that there is a $1,000 annual allowance each year for preventive and comprehensive dental services. The Plan also says that the annual allowance has been exceeded.

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. We find that the Plan did not provided documentation to substantiate the claim that the allowance had been exhausted prior to the date of service in this case. We are not able to determine if the annual allowance has been reached. Therefore, we decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 20, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) provided on March 17, 2021.

You asked the Plan to waive the copayment for the computed tomography, thorax (71260). You say that you were assured the CT was covered. The Plan denied your request. The Plan says the CT is covered and you were charged this copayment 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 $100 copayment for Outpatient diagnostic tests, hospital facility. 

You have been asked to pay a $100 copayment for the computed tomography, thorax (71260). The computed tomography, thorax (71260) falls within the Outpatient Diagnostic Tests, hospital facility 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 computed tomography (CT) provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery provided by a participating provider.

You asked the Plan to pre-approve an esophagogastroduodenoscopy. You say that these services are medically necessary. You say that these services are needed to prevent further damage. The Plan denied your request. The Plan says these services can be provided as an outpatient.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an esophagogastroduodenoscopy. Our reviewer says that this does not meet approval for inpatient level of care. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve an outpatient surgery provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient admission and services provided on May 6, 2019 to May 16, 2019 by an out-of-network (OON) provider.

You asked the Plan to pay for the inpatient care. You say that this care was medically necessary. The Plan denied your request. The Plan says no referral or prior authorization was requested or granted for the dates in question. The Plan was not notified prior to services.

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. A referral or prior authorization is required for inpatient care at an out-of-network hospital.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the inpatient admission and services provided on May 6, 2019 to May 16, 2019 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 18, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide positron emission tomography (PET) imaging.
You asked the Plan to provide positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). You say that the PET is to follow multiple nodules seen. The Plan denied your request. The Plan says PET imaging is not indicated.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 provide positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). Our reviewer says that the service is not medically necessary. Our physician reviewer found patient has stable pulmonary nodules thus not a high suspicion of metastasis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) have not been met. Therefore, we decided that the Plan does not have to provide positron emission tomography (PET) imaging.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the drainage of a hand tendon sheath provided on March 3, 2021.

You asked the Plan to pay for the tendon sheath drainage procedure. You say that this should be separately payable. The Plan denied your request. The Plan says this would be included in the global surgical package for the procedure provided on February 26, 2021.

The Plan must follow Medicare rules. Medicare rules say that during the global period of a surgical related surgical procedures to treat complications or unrelated procedures by the same surgeon may be separately paid if they are billed with the appropriate modifier. 

We looked at the file and Medicare rules. In this case, the Plan made payment for the procedure 26020 for date of service February 26, 2021. This procedure has a 90-day global period. This second surgery incidentally described by the same code was provided within that global period. Although it appears that this may be unrelated to the first procedure, no modifier was appended as is required in order to receive separate payment during the global surgical period. Based on this information, we decided that Medicare rules for coverage of the tendon sheath drainage procedure have not been met. Therefore, we decided that the Plan does not have to pay for the drainage of a hand tendon sheath provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that without the rehab services you will never be able to recover properly. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical management of a tibial plateau fracture. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the scanning computerized ophthalmic diagnostic imaging (91324) provided July 14, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you had a major surgical repair on May 28, 2021. This appointment on July 14, 2021 falls within the 90-day post-surgical global period. There is no charge or copayment for post-operative visits if it is for the same condition. The Plan denied your request. The Plan says that per CMS it was confirmed you are allowed a 20-day post-op exam, which means your post-operative exam would have had to be rendered by June 17, 2021. Therefore, the claim processed correctly with a $15 copayment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 for other outpatient diagnostic tests for Outpatient diagnostic tests and therapeutic services and supplies. 

The Plan says you must pay $15 for a specialist office visit. The service at issue is a diagnostic service. Diagnostic services are not included in the global surgical package. Based on the Plan contract, you cannot be asked to pay more than $0 for other outpatient diagnostic tests for the diagnostic service. The health plan contract specifically says there is no coinsurance, copayment, or deductible for Medicare covered outpatient diagnostic procedures or tests. Therefore, we decided that the Plan has to waive the copayment for the scanning computerized ophthalmic diagnostic imaging (91324) provided July 14, 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.