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

 We decided that the Plan does not have to waive the coinsurance for air ambulance services you received on August 2, 2021.  You asked the Plan to waive the coinsurance for the air ambulance services. You say that you think this is an unfair charge as there was no discussion with you about the use of an air ambulance as opposed to a ground ambulance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for air ambulance services.   You have been asked to pay 20% coinsurance for the air ambulance services. This cost sharing applies regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for air ambulance services you received on August 2, 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 the enrollee was independent prior to the hip fracture. The Plan denied your request. The Plan says the enrollee does not require an intensive rehabilitation therapy program 3 hours a day.  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 physician reviewer found that the enrollee suffered a left hip fracture and is status post-surgery with no complications documented. She is at a moderate assist level for mobility and transfers, minimal assist with a rolling walker, moderate assist for toilet transfers, and total assist for toileting hygiene. She has no acute nursing needs. She does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.  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: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on June 23, 2021.  You asked the Plan to waive the coinsurance for the Prolia injection. You say that had you known of the cost, the enrollee would not have gotten the shot.  You stated that under the enrollee's previous insurance, there was no cost sharing for this injection. The Plan denied your request. The Plan says this coinsurance was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B drugs.   The enrollee has been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B drugs benefit category. This cost sharing applies regardless of what the enrollee may have paid with other insurance.   This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of a peripheral nerve stimulator (electro-acupuncture device).  You asked the Plan to pre-approve electro-acupuncture device. You say that it was determined that the enrollee would be an excellent candidate for this service. The Plan denied your request. The Plan says this electro-acupuncture device is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that use of electro-acupuncture devices is not covered by Medicare.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a peripheral nerve stimulator (electro-acupuncture device).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on April 29, 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 20999 is 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 20999 is unlisted procedure, musculoskeletal system, general.  We find that CPT code 20999 is not supported in the medical record. Specifically, there is no documentation of an unlisted procedure identified by "special report". Based on this information, we decided that Medicare rules for coverage of these services have not been met.  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 27726 (repair of fibula) and 20680 (removal of support implant). Code 20680 is a column II code with a modifier indicator of 1 when billed with column I code 27726. Code 20680 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 surgical services rendered on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on July 7, 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 there is no valid physician order.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.   We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on July 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 74018 provided on July 14, 2021.  You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the x-ray services is a column II code to column I code 74018 for 74250. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 74018 provided on July 14, 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 the SNF services. You say that the enrollee is very weak and needs care. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy services. The Plan says that the enrollee does not have any daily skilled nursing needs. The Plan says that the enrollee's needs can be met at a lower level of care.  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 there is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, but they are not required on a daily basis. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the home with home health services or in a long-term care facility on a part time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an X-ray of the hip provided on August 9, 2021.  You asked the Plan to waive the copayment for an X-ray. You say that you had an ultrasound on the same day and were advised by the provider that only one copayment would apply. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each standard X-ray and ultrasound.   You have been asked to pay $45.52, which is less than the $50 copayment for an X-ray. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray of the hip provided on August 9, 2021.   Your complaint about the misinformation from the provider 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sandostatin injection.
You asked the Plan to pre-approve Sandostatin. You say that without the shot, the enrollee will start GI bleeding. The Plan denied your request. The Plan says medical studies have not proven the drug is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Sandostatin. Our physician reviewer found that the enrollee has anemia, and has been receiving monthly Sandostatin injections, ostensibly to reduce his risk of bleeding from gastrointestinal AVM's. Per standard-of-care, Somatostatin is not recommended for routine use with acute non-variceal upper GI bleeding. It may serve as adjunctive therapy in settings in which endoscopy is unavailable or as a means to help stabilize patients before definitive therapy can be performed. These instances are not the enrollee's situation. The enrollee has readily responded to endoscopic hemostasis on each occasion it was applied to him. Therefore, the requested injection is not considered medically reasonable or necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sandostatin have not been met. Therefore, we decided that the Plan does not have to pre-approve a Sandostatin injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four retainer crowns (D6740) provided on August 5, 2021.  You asked the Plan to pay for retainer crowns. You say that these services should be covered because your benefit covers crowns. The Plan denied your request. The Plan says retainer crowns are not covered by your dental benefit. The Plan also says that you contacted them regarding covered dental services and were mailed a document which lists all covered services with their identifying procedure codes. Code D6740 is not listed as a covered service in this document.  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 four retainer crowns (D6740) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) or pay more for the resin-based composite (D2391) provided on June 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the first intraoral periapical x-ray and to pay more for the resin-based composite. You say that you needed the lift chair to sleep in while you were recovering from open heart surgery. The Plan denied your request. The Plan says the first intraoral periapical x-ray is not a covered expense under your dental plan. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.  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, first intraoral periapical x-ray (D0220) is not among those covered under this benefit. You are also responsible for a 50% coinsurance for composite restorations plus the difference between the billed amount and the allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) or pay more for the resin-based composite (D2391) provided on June 2, 2021 by an out-of-network (OON) provider.   Please Note: The Plan only sent a decision about dental services to us and no case file was sent to us regarding the other items in your appeal letter. You may wish to contact the Plan directly for more information on how this other portion of the appeal was handled.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of portable x-ray equipment rendered on June 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 are not covered.  The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.  We looked at the file and Medicare rules. Billed procedure code R0070 (transportation of portable x-ray equipment) has a PC/TC indicator of 3 and no separate PC payment. 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 transportation of portable x-ray equipment rendered on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on February 3, 2021, through February 6, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $160 copayment each day one through five for inpatient hospital care.   You have been asked to pay a $160 copayment each day one through five for the inpatient hospital care. the inpatient hospital care falls 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 hospital care provided on February 3, 2021, through February 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra 5% drops.  You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 pre-approve Xiidra 5% drops.    Benefits for Xiidra 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on June 1, 2021.  You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you only spoke on the phone for 5 minutes, and you feel there should not be a copayment for this. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for physician specialist services, including surgery second opinions, telehealth services, and urgently needed services.  You have been asked to pay a $50 copayment for the telehealth specialist visit. Specialist telehealth visits fall 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 copayment for a specialist telehealth visit provided on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the imaging services rendered on March 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 procedure codes 70450, 70496, 70498, and 0042T are 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 70450 is computed tomography, head or brain, without contrast material. The definition of code 70496 is computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing. There is no documentation of 70498 is computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing. The definition of code 0042T is cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time.  We find that CPT codes 70450, 70496, 70498, and 0042T are not supported in the medical record. Specifically, there is no documentation of a CT of the head/brain without contrast material to support code 70450. There is no documentation of a CTA of the head with contrast to support code 70496. There is no documentation of CTA neck with contrast material to support code 70498. There is no documentation of cerebral perfusion analysis using CT with contrast to support code 0042T. 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 imaging services rendered on March 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health office visits rendered by the out-of-network (OON) provider on August 4, 2021 and August 20, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 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 outpatient mental health office visits rendered by the out-of-network (OON) provider on August 4, 2021 and August 20, 2021.