Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) electronic analysis of implanted neurostimulator pulse generator system (95982) provided on June 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the clinic visit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 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 hospital outpatient clinic visit (G0463) electronic analysis of implanted neurostimulator pulse generator system (95982) provided on June 9, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided from November 5, 2019 to December 31, 2019.

You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that therapy services may be covered if a qualified therapist has completed the reassessment and objective measurement of the effectiveness of the therapy as it relates to the therapy goals.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Specifically, the record does not support that the criteria for the reassessment have been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided from November 5, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) provided on August 10, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that your copayment should be $30 instead of $40. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $40 copayment for Physician/Practitioner Services, Including Doctor's Office Visits, specifically specialist visits rendered by tier 2 providers.

You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that the provider seen is an out-of-network provider but is part of a group that is contracted and considered a tier 2 provider, meaning that the $40 copayment applies instead of the $30 for tier 1 providers. 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 specialist office visit (99203) provided on August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for endovenous ablation therapy services provided on July 7, 2021, by an out-of-network provider.

You asked the Plan to pay for endovenous ablation therapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

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 endovenous ablation therapy services provided on July 7, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2394) provided on September 27, 2021.

You asked the Plan to pay for the resin-based composite. You say that this service is not listed as an exclusion under your Benefits and Exclusions. You also say that you feel strongly that payment is appropriate since the service is not listed. The Plan denied your request. The Plan says this service is not a benefit under the 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 resin-based composite (D2394) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for inpatient hospital care from April 28, 2020, through May 5, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the copayment because you were released from one hospital and admitted again within 24 hours for the same diagnosis. The Plan denied your request. The Plan says that you were admitted to a different hospital which was not affiliated or the same as the previous hospital admission, therefore the copayment was applied correctly.

The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically necessary, and if the readmission did not result from a premature discharge from the same hospital. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have been met. Specifically, readmission review involves admissions to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or another acute, general, short-term hospital. Therefore, we decided that the Plan has to waive the copayment for inpatient hospital care from April 28, 2020, through May 5, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services the enrollee needs can be provided at another level of care.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for gastrointestinal bleeding. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the crown (D2740) provided on July 16, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that you told the dentist to not go over your dental allowance as you cannot afford to pay anything out of pocket. You say that you received a statement showing the services were submitted with an overage. You say that you left with a cracked tooth. You also say that a temporary crown was made and then a partial was made and now you have a bill for $166. The Plan denied your request. The Plan says there is an allowance of $2,000 for supplemental preventive and comprehensive dental services every year. The Plan also says that the allowance has been exhausted while processing this claim.
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 annual allowance of $2,000 has been exhausted. The record shows that the Plan paid $155 for services received on January 19, 2021, $207 for services received on July 7, 2021, $925 for services received on July 26, 2021, and $713 for services received on July 16, 2021. $155 + $207 + $925 + $713 = $2,000. Additionally, the Evidence of Coverage clearly states you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay an additional amount for the crown (D2740) provided on July 16, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitrectomy support equipment (E1399) and fuel surcharge (E1399), purchased on August 3, 2021.

You asked the Plan to pay for the vitrectomy support equipment and fuel surcharge. You say that the items should be covered. The Plan denied your request. The Plan says you obtained these items through a provider that does not participate with Medicare.

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 the vitrectomy support equipment (E1399) and fuel surcharge (E1399), purchased on August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport
(A0429, A0425) provided on July 22, 2019.

You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your
request. The Plan says the claim was filed untimely and denied correctly.

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 ambulance service, basic life support, emergency transport was not filed until
June 21, 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 ambulance service, basic life support,
emergency transport (A0429, A0425) provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 31, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that the provider's office got permission to perform the periodontal scaling, but you got a bill for the service. You also say that you are not being charged for your visit on August 31, 2021 to pay for the services provided during your visit on January 29, 2021. The Plan denied your request. The Plan says this service is not covered.

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 periodontal maintenance (D4910) provided on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided March 27, 2021 to April 1, 2021.
You asked the Plan to pay for the inpatient services. 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnoses of A41.51, (Sepsis due to Escherichia coli [E. coli]), R65.20, (Severe sepsis without septic shock) and I21.A1, (Myocardial infarction, type 2). 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 services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the documentation received supported an admission for a catheter associated urinary tract infection. While sepsis/severe sepsis was documented in the history and physical examination, consultant and attending progress notes and the discharge summary, other provider documentation was incomplete regarding this condition. The principal diagnosis of T83.511 (Infection and inflammatory reaction due to indwelling urethral catheter) was not supported by the documentation. The diagnosis codes A41.51, (Sepsis due to Escherichia coli [E. coli]), R65.20, (Severe sepsis without septic shock) and I21.A1, (Myocardial infarction, type 2) as secondary diagnoses on this claim were not supported by the documentation. The DRG billed was not supported by the documentation. 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 services provided March 27, 2021 to April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Neuromuscular Electrical Stimulation (NMES) (E0745).

You asked the Plan to pay for the Neuromuscular Electrical Stimulation. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. 

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 Neuromuscular Electrical Stimulation. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not note a spinal cord injury or disuse atrophy. 

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 Neuromuscular Electrical Stimulation have not been met. Therefore, we decided that the Plan does not have to pay for the Neuromuscular Electrical Stimulation (NMES) (E0745).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from July 2, 2021, to July 3, 2021.

You asked the Plan to pay for the self-administered drugs. You say that the bill for drugs that were used after your surgery and prescribed by your doctor should have been covered by your insurance.

The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from July 2, 2021, to July 3, 2021.

Benefits for the self-administered drugs 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 pay for the ankle x-ray rendered on July 20, 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 73600 is 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 73600 (ankle x-ray, two views) and 73610 (complete ankle x-ray, minimum of three views). Code 73600 is a column II code with a modifier indicator of 1 when billed with column I code 73610. Code 73600 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 ankle x-ray rendered on July 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425) provided on July 22, 2021.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you are unable to afford the 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 $260 copayment for ambulance services. 

You have been asked to pay a $260 copayment for emergency ambulance transportation. The service at issue falls within the ambulance services 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 emergency ambulance transportation (A0429, A0425) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day. 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 continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 11, 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 76705 is 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 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 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 abdominal ultrasound rendered on August 11, 2021