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

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 15, 2021, through April 5, 2021.  You asked the Plan to pay for the SNF services. You say that you were not able to care for yourself after your hospital stay due to losing your hearing aid and your weight loss from COVID infection. The Plan denied your request. The Plan says you did not require daily skilled care on these dates.  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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF from March 15, 2021, to April 5, 2021. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need during these dates. The documentation does not support that during the dates from March 15,2021 to April 5,2021 the patient's functional level required skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The documentation does not support that the patient required skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF.  As a practical matter, this patient did not require the necessary services on an inpatient basis, in a skilled nursing facility setting during the dates in question.  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 pay for the skilled nursing facility (SNF) services provided from March 15, 2021, through April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for orthopedic services provided to the enrollee on July 21, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes are inclusive to other procedures.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 63047 and 63048 are not supported in the medical record. Specifically, these codes are inclusive to CPT 22633 and CPT 22634, respectively, and cannot be billed separately. 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 pay for orthopedic services provided to the enrollee on July 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from May 7, 2021 to June 5, 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 enrollee exhausted the benefit limit.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that the enrollee received 100 days of SNF care during the benefit period from September 18, 2020 to May 6, 2021. The Plan has covered 100 days of SNF care.   Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from May 7, 2021 to June 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical assistant services provided during a removal of implant on May 25, 2021, billed with code 20680-AS.  You asked the Plan to pay for the surgical assistant services. You say that this should be paid. The Plan denied your request. The Plan says there is no rationale to support the need for a surgical assistant in this case.  The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 20680. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.   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 surgical assistant services. Our reviewer says that the surgical assistant services are not shown to be medically necessary. Our physician reviewer found for the requested surgery, CPT code 20680, there is a "0" in the assistant surgeon column. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for the 20680 (removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod, or plate) is 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 surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided during a removal of implant on May 25, 2021, billed with code 20680-AS.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on April 30, 2021.  You asked the Plan to waive the copayment for the outpatient hospital services. You say that the services should be covered as you cannot afford to pay them. 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 $325 copayment for Outpatient hospital services.   You have been asked to pay a $325 copayment for outpatient hospital services. The record indicates t hat these services were performed in an outpatient setting. 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 outpatient hospital services provided on April 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve repeat transcranial magnetic stimulation (90867, 90868, 90869).  You asked the Plan to pre-approve repeat transcranial magnetic stimulation. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.  The Plan follows Medicare rules. Medicare rules say that patients must have responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms.  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 repeat transcranial magnetic stimulation. Our reviewer says that the requested procedure is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not meet the clinical criteria for the repeat use of transcranial magnetic stimulation therapy as records submitted does not document improvement in the enrollee's depression based on the Personal Health Questionnaire Depression Scale (PHQ-9).  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat transcranial magnetic stimulation have not been met.  Therefore, we decided that the Plan does not have to pre-approve repeat transcranial magnetic stimulation (90867, 90868, 90869).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided July 23, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that it was not your decision that you needed to be transferred. 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 $250 copayment for each one-way Medicare-covered ground trip by ambulance.  You have been asked to pay a $250 copayment for the emergency ambulance services. The emergency ambulance services fall 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided July 23, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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.  Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for IV Infusion services (96360) provided on March 29, 2021, to July 20, 2021.  You asked the Plan to waive the copayment for the IV Infusion services. You say that the services should be covered as you were informed by a Plan representative that there would be a $20 copayment per visit. 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 $370 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   You have been asked to pay a $197.37 copayment for five visits of IV Infusion services, which is less than the $370 stated in the Plan's contract ($197.37 x 5 = $986.85). There is no record of any contact between you and the Plan regarding the copayment that would apply. IV Infusion services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 IV Infusion services (96360) provided on March 29, 2021, to July 20, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for emergency department visits provided from August 9, 2021, to August 17, 2021.  You asked the Plan to waive the copayments for emergency department visits. You say that there was overcrowding, chaos, and long wait times in the emergency department. You also say that you were not seen by a medical doctor at either emergency department visit and that you left without a discharge at both emergency department visits. You also say that you should only be held responsible for the computed tomography scan and the provider that read that film. 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 $120 copayment for each Emergency Room visit.   You have been asked to pay a $120 copayment for each emergency department visit for two visits. Although you left before being discharged, the record shows you were seen at the emergency room department. 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 emergency department visits provided from August 9, 2021, to August 17, 2021.   Your complaint about the potential chaos and disorganization 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided a participating provider on August 16, 2021, to August 19, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were in the intensive care solely due to the lack of regular rooms following recovery. The Plan denied your request. The Plan says the correct copayment has 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 $295 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.    You have been asked to pay a $295 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $885 ($295 x 3 days = $295). An inpatient hospital stay 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 an inpatient hospital stay provided by a participating provider on August 16, 2021, to August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Diovan.  You asked the Plan to pre-approve Diovan. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Diovan.       Benefits for Diovan 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 podiatry visit provided on July 13, 2021. We also decided that the plan does not have to waive the coinsurance for foot and ankle orthosis provided on July 13, 2021.  You asked the Plan to waive the copayment and coinsurance for the podiatry visit and foot and ankle orthosis. You say that you cannot afford these charges. The Plan denied your request. The Plan says the correct copayment and coinsurance was 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 $5 copayment for each podiatry visit.   Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each durable medical equipment (DME) item, including foot and ankle orthosis.  Item/Service Allowed Amount Copayment/Coinsurance Podiatry Visit $83.07 $5 (Copayment) Ankle/Foot Orthosis (L4397) $164.40 $32.88 (20% Coinsurance) Ankle/Foot Orthosis (L4397) $164.40 $32.88 (20% Coinsurance) Ankle/Foot Orthosis (L1971) $459.24 $91.85 (20% Coinsurance) Ankle/Foot Orthosis (L1971) $459.24 $91.85 (20% Coinsurance) Ankle/Foot Orthosis (L2820) $93.61 $18.72 (20% Coinsurance) Ankle/Foot Orthosis (L2820) $93.61 $18.72 (20% Coinsurance) Total:  $291.90  You have been asked to pay $291.90 for the podiatry visit and foot and ankle orthosis. The podiatry visit falls within the Podiatry Services benefit category. The foot and ankle orthosis falls within the Durable Medical Equipment (DME) and Related 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 a podiatry visit provided on July 13, 2021. We also decided that the plan does not have to waive the coinsurance for foot and ankle orthosis provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from April 9, 2021, to April 29, 2021.  You asked the Plan to waive the copayments for the physical therapy visits. You say that you do not believe your mother was receiving physical therapy services. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for in-network physical, speech, and occupational therapy.    The enrollee has been asked to pay a $20 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient Rehabilitation Therapy" benefit category. The medical record shows physical therapy services were rendered. 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 copayments for the physical therapy visits provided from April 9, 2021, to April 29, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on August 27, 2021.  You asked the Plan to pay for the emergency department visit. 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 separately payable.  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 99284 for the emergency department visit is a column II code to column I code 99285. 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 emergency department visit coded 99284 provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglass lenses (V2500) purchased on July 16, 2021.  You asked the Plan to pay for the lenses. You say that these lenses are necessary for you and should be covered. The Plan denied your request. The Plan says there is a $240 benefit allowance toward the purchase of eyewear every 24 months. You previously used this benefit in January of 2020, and the Plan paid the full allowance for the services provided at that time. Therefore, this service is denied as your benefit was exhausted on the date in question.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $240 for eyewear every 24 months.  We looked at the file and the Plan's rules. Documentation shows that you previously used the full benefit allowance in January of 2020, which is less than 24 months prior to the date in question. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass lenses (V2500) purchased on July 16, 2021.