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

We decided that the Plan does not have to pay for the inpatient hospital services provided December 29, 2019, through December 30, 2019.

You asked the Plan to pay for the inpatient hospital services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has been filed outside the timely filing guidelines.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the inpatient hospital services was not filed until February 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided December 29, 2019, through December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen and related equipment.
You asked the Plan to pre-approve oxygen and related equipment. You say that you have been living with pneumonia on both lungs for a year this February. The Plan denied your request. The Plan says the requested home use of oxygen and related equipment is not medically necessary. The Plan says that they have approve a temporary oxygen supply for 1 month, and that this is sufficient.
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements.
In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. 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 oxygen and related equipment. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), and reportedly is on home oxygen at 2 Lpm. The enrollee was hospitalized for pneumonia in October 2021. The discharge summary does not include room air oxygen saturations or arterial blood gases. There is no other information to support the need for oxygen. There is no Certificate of Need. The Plan has appropriately approved home oxygen for 1 month to allow time for the information to be provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen and related equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen and related equipment
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on September 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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 71045
is a column II code to column I code 71046. 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 services (71045) provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint for the enrollee.
  
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says radiofrequency neuroablation of the nerves innervating the sacroiliac joint has not been proven as effective as standard treatment of sacroiliac joint pain.  

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational because of the wide variation of efficacy reported in the literature. Therefore, the request is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is improving but has oxygen desaturation with exertion and requires high
flow oxygen. The record indicates that the enrollee requires ongoing acute care services, and these have not
been denied. The medical record does not indicate that the enrollee requires services that he is not currently
receiving but that would be available at the LTACH facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided by an out-of-network (OON)
provider on May 5, 2021.
You asked the Plan to pay for the OON telehealth services. You say that this was medically necessary. The
Plan denied your request. The Plan says there is no coverage for telehealth services when provided OON.
The Plan must follow Medicare rules. Medicare rules say that Plans are only allowed to offer telehealth
benefits through network providers. This is reiterated in the Plan's contract.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the OON telehealth services have not been met. Therefore, we decided that the Plan does not have
to pay for the telehealth services provided by an out-of-network (OON) provider on May 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the gloves coded A4930 provided on August 30, 2021.
You asked the Plan to pay for the gloves. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the items billed are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid.
In this case, the MUE for CPT code A4930 is 0. The MAI value for this code is 3. You billed 1 unit of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
gloves have not been met. Therefore, we decided that the Plan does not have to pay for the gloves coded A4930
provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telephone evaluation and management service by a
physician (99442) provided on April 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a telephone evaluation and management service by a physician. You say that this
exam was medically necessary for this patient and have submitted supporting documents. The Plan denied your
request. The Plan says the service provided requires prior authorization and no authorization has been obtained.
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 a telephone
evaluation and management service by a physician (99442) provided on April 28, 2021, by an out-of-network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusion analysis services provided on June 15, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee did not have a choice of
perfusion providers. The Plan denied your request. The Plan says the codes are included in the payment made
to the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility for services furnished to a beneficiary.
We looked at the file and the rules. The records show that the enrollee was receiving inpatient care at the time
the services were provided. The facility must furnish all necessary covered services to the beneficiary either
directly or under arrangements made with outside providers. This service was provided via arrangement of the
facility. Payment for this service would have been included under the facility claim. Payment to you for this
service is the responsibility of the facility. Based on this information, we decided that Medicare rules for
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay
for the perfusion analysis services provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a drug injection provided on September 
22, 2021.

You asked the Plan to waive the coinsurance for a drug injection. You say that you cannot afford all of the 
charges you are receiving. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct 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 20% 
coinsurance for Medicare Part B prescription drugs. 

You received a drug injection on September 22, 2021. The total allowed amount is $13.60 and 20% of that is 
$2.72.

You have been asked to pay the total coinsurance amount of $2.72 for a drug injection. A drug injection falls 
within the Medicare Part B prescription drugs 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 coinsurance for a drug injection provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional months (for a total of 10 months) of rental
of a heavy duty manual wheelchair (K0006) and a non-standard seat frame (E2201).
You asked the Plan to pre-approve additional months of a heavy duty manual wheelchair and a non-standard
seat frame. You say that the requested items are a medical necessity for you. The Plan denied your request. The
Plan says medical necessity rules for coverage of the requested items have not been met.
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 a heavy duty manual wheelchair and a
non-standard seat frame. Our reviewer says that the requested items are not considered medically reasonable
and necessary in this case. Our physician reviewer found that provided records do not document need for the
equipment for a total of 10 months.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional months of a heavy duty manual wheelchair and a non-standard seat
frame have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional months
(for a total of 10 months) of rental of a heavy duty manual wheelchair (K0006) and a non-standard seat frame
(E2201).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (L5-S1).
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due
to insufficient evidence of efficacy.
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 the procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental. More research is needed to show safety and efficacy.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure (L5-S1).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 22, 2021 by an out-of-
network (OON) provider.
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 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 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 drug testing provided on July 22, 2021 by an
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code E1399).
You asked the Plan to pre-approve the compression stockings. You say that the items are medically necessary.
The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399) are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7140), an osseous, osteoperiosteal, or
cartilage graft (D7950), intravenous sedation, first 15 minutes (D9239) and intravenous sedation, each 15-
minute increment (D9243) provided on November 6, 2019.
You asked the Plan to pay for dental services. You say that this claim should have been processed as medical
services and not dental services as these services were performed due to cancer. The Plan denied your request.
The Plan says the medical records submitted by the provider document the dental services performed were not
performed in preparation for radiation therapy. The medical records document the services were related to a
broken implant and your chief complaint and reason for the dental visit was documented as the upper bridge is
mobile.
Medicare generally does not cover dental services. The Plan follows the same rule.
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. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7140), an
osseous, osteoperiosteal, or cartilage graft (D7950), intravenous sedation, first 15 minutes (D9239) and
intravenous sedation, each 15-minute increment (D9243) provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for lab services and outpatient surgeries from August 2, 2021, to August 24, 2021.
You asked the Plan to waive the copayments for the lab services and outpatient surgeries. You say that you paid the bill and keep on receiving bills for the dates of service. The Plan denied your request. The Plan says the proper copayments have been applied.
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 $35 copayment for Medicare-covered lab services and a $350 copayment for each Medicare-covered outpatient surgical service.
On August 2, 2021, you were charged a total amount of $16.23 for lab services. Since that is less than the amount of the $35 copayment only $16.23 was charged for the copayment. On August 5, 2021, you were charged a total amount of $425.38 for outpatient surgery since the charges were more than the copayment only $350 was charged for the copayment. On August 12, 2021, you were charged a total amount of $316.66 for outpatient surgery since the charged were less than the copayment only $316.66 was charged for the copayment. On August 24, 2021, you were charged a total amount of $316.66 for outpatient surgery since the charged were less than the copayment only $316.66 was charged for the copayment. The total copayment amount for the dates of service is $999.55. You have been asked to pay a total of $983.32 copayment for lab services and outpatient surgeries. Lab services falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category.
Outpatient surgery falls within the Outpatient hospital 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 copayments for lab services and outpatient surgeries from August 2, 2021, to August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Phonak Paradise Rechargeable RIC hearing aid in the left ear and a Phonak CROS Paradise Rechargeable hearing device in the left ear.
You asked the Plan to pre-approve a Phonak Paradise Rechargeable RIC hearing aid in the left ear and a Phonak CROS Paradise Rechargeable hearing device in the left ear. The Plan denied your request. The Plan says benefit is limited to only the Plan hearing aid provider's Advanced or Premium hearing aids, both of which come in various styles and colors. The Plan's hearing aid provider does offer this type you are requesting "BiCROS and CROS" under the premium and advanced hearing aids.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the hearing aid benefit is covered by the Plan's hearing aid provider only. Therefore, we decided that the Plan does not have to pre-approve a Phonak Paradise Rechargeable RIC hearing aid in the left ear and a Phonak CROS Paradise Rechargeable hearing device in the left ear.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metoprol tartrate for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Metoprol tartrate is a self-administered drug.

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 Metoprol tartrate for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crutch substitute (E0118).
You asked the Plan to pre-approve the crutch substitute. 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 items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or
the Plan. Therefore, we decided that the Plan does not have to pre-approve the crutch substitute (E0118).