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

 We decided that the Plan does not have to pre-approve the records provided support the need for SNF care.  You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says there is no documentation of daily skilled needs.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee appears to be able to accomplish self-care tasks and mobility independently but continues to require high flow oxygen therapy.  There are no available updated medical records that support that she is stable for discharge or requires services available at a skilled nursing facility.   The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis.   Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube.  When she is medically stable, she can receive further rehabilitation services at a lower level of care.  Her physical function is at or near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehab services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the records provided support the need for SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Eylea injections you received from March 19, 2021, to September 3, 2021.  You asked the Plan to waive the coinsurance for the Eylea injections. You say that you cannot afford this coinsurance and these injections are needed to keep from going blind. 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 Medicare Part B drugs.    You have been asked to pay 20% coinsurance for the Eylea injections. The Eylea injections fall within the Medicare Part B 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 the Eylea injections you received from March 19, 2021, to September 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you are unable to take medications or take care of yourself without assistance. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are receiving adequate care in the inpatient rehabilitation facility.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the most recent therapy documentation indicates you are able to ambulate up to 75 feet using a cane with contact-guard assistance. You accomplish bed mobility and transfers with contact guard assistance. You are medically stable and do not have any complex daily wound care, parental medications or required care for a new or malfunctioning feeding tube. You have tolerated inpatient rehabilitation services and continue to improve with daily skilled nursing and/or skilled therapy services.  There is no indication that a transfer to a skilled nursing facility is required.  You can continue to receive skilled services at the current inpatient rehabilitation facility. There are no services offered at a SNF that are not offered at an inpatient rehab facility.  Therefore, an admission to a SNF for inpatient skilled rehab services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the epidural injection procedure you had at an outpatient hospital facility on June 23, 2021.  You asked the Plan to waive the copayment for the injection procedure. You say that you had a $40 copayment for this service in the past. The Plan denied your request. The Plan says 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 $300 copayment for outpatient surgery and services provided at hospital outpatient facilities.   You have been asked to pay a $300 copayment for the injection procedure. This copayment applies regardless of what you may have paid in the past. 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 epidural injection procedure you had at an outpatient hospital facility on June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Synvisc injections you received on July 7, 2021, and July 26, 2021.  You asked the Plan to waive the coinsurance for the Synvisc injections. You say that you were not aware that this drug was only 80% covered.  You said that had you known of this expense, you would have declined the services. 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 Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Synvisc injections. The Synvisc injections fall within the Medicare Part B 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 the Synvisc injections you received on July 7, 2021, and July 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient telehealth mental health care services you received on June 14, 2021, and July 12, 2021.  You asked the Plan to waive the copayments for the outpatient telehealth mental health services. You say that you cannot afford these copayments and you were told that telehealth copayments were waived. The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan says that there are no phone records showing that you were told that telehealth services would have the copayments waived.  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 $30 copayment per visit for outpatient telehealth mental health care.   You have been asked to pay a $30 copayment per visit for the outpatient telehealth mental health services. There is no provision in your contract for a waiver of these copayments. 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 outpatient telehealth mental health care services you received on June 14, 2021, and July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a portable ventilator. You say that the medical records provided support the need for a portable ventilator. The Plan denied your request. The Plan says a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bi-level positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease.    The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability.  The Plan has indicated such a device is available for 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 a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on May 28, 2021.  You asked the Plan to pay for the Guardant360 CDx testing. You say that this is a covered test according to Medicare rules. The Plan denied your request. The Plan says this was not reported with the correct POS code.  The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.  We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx testing provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (00630) provided on May 28, 2021.  You asked the Plan to pay for the anesthesia 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 supported.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no anesthesia records provided to verify the code billed, the number of units billed, and the modifiers billed. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00630) provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99203) rendered on July 2, 2021.  You asked the Plan to waive the copayment for an office visit with a specialist. You say that you went to see your primary doctor, however, he was unavailable, so you were directed to another provider on staff. You also say the provider you saw is not a specialist. The Plan denied your request. The Plan says you were 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 $45 copayment for per provider per day for a specialist.   You have been asked to pay a $45 copayment for an office visit with a specialist. The record shows that the provider who provided the office visit is an emergency medicine specialist. 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 office visit with a specialist (99203) rendered on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require daily skilled therapy services.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided from December 22, 2020, through March 11, 2021.  You asked the Plan to pay for the additional supplies and materials. You say that this new code was established to report additional practice expenses incurred during a public health emergency and the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from December 22, 2020, through March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided on July 28, 2021.  You asked the Plan to pay for dental services. You say that you were not aware that your limit was $1,000 annually and you are on a fixed income. The Plan denied your request. The Plan says the denial of payment for these services is correct, because your $1,000 annual maximum has been exhausted so you are responsible for any remaining charges.  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 Plan covers dental services up to an annual maximum benefit of $1,000.   We looked at the file, the Plan's rules, and Medicare rules. You have exhausted the $1,000 annual maximum benefit for dental services; therefore, you are responsible for any additional charges. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for dental services provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the neurology visit you had on  March 10, 2021.  You asked the Plan to waive the copayment for the neurology visit. You say that you received these services while at your pain clinic, so there should not be a separate copayment. The Plan denied your request. The Plan says they confirmed with medical records that these neurology services were not performed on the same day as an office visit with your pain clinic.  You were at the pain clinic on March 1, 2021, and March 15, 2021.  These neurology services occurred on March 10, 2021.  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 per visit for services with a specialist.      You have been asked to pay a $40 copayment per visit for the neurology visit. The neurology visit falls within the services with a specialist 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 neurology visit you had on March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on June 3, 2021.  You asked the Plan to pay for code 70450. 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 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 70450 is a column II code to column I code 70496. 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 computed tomography (CT) scan (70450) provided on June 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on June 16, 2021.  You asked the Plan to pay for code A0429. 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 as billed.  The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.  We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services represented by code A0429 provided on June 16, 2021.