Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the continuous positive airway pressure (CPAP) device and supplies provided on April 28, 2021.  You asked the Plan to waive the deductible for the CPAP device and supplies. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says they have reprocessed the claims for payment; however, you have not met your 2021 deductible for the year, therefore, $207.47 has applied towards your deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 deductible which applies to Durable medical equipment.   The item or service you asked the Plan to waive the deductible for falls within the benefit category Durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to Durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the CPAP device and supplies was received on April 28, 2021.  Therefore, we decided that the Plan does not have to waive the deductible for the continuous positive airway pressure (CPAP) device and supplies provided on April 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on August 16, 2021.  You asked the Plan to pay for the ambulance service. You say that you were stung by yellow jackets and were sweating profusely. You say that you were advised to call 911. You say that your rash was disappearing and you were feeling better so you refused transport. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since no transport was provided there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on August 16, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a pulmonology visit provided on  July 14, 2021.  You asked the Plan to waive the copayment for specialist visit. You say that this was a follow-up visit so you should not be responsible for a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  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 $25 copayment for specialist visit. You previously received a follow-up visit on May 7, 2021, which the Plan covered with $0 copayment for you, so the $0 copayment does not apply to this claim.   You have been asked to pay $25 copayment for specialist visit. Specialist visit falls 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 pulmonology visit provided on July 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided on June 8, 2021.  You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that the cost is an error and should be disallowed. The Plan denied your request. The Plan says the coinsurance 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 20% of the cost of Medicare-covered services.    You have been asked to pay $122.44, which is 20% of the allowed amount for the leuprolide acetate suspension. The allowed amount is $612.21 (20% x $612.21 = $122.44). The leuprolide acetate suspension 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 the leuprolide acetate suspension provided on June 8, 2021.
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) provided August 8, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you don't feel you should have to pay because the wrong provider serviced you. 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 $275 copayment per one-way trip by ground or air ambulance.  You have been asked to pay a $275 copayment for the emergency ambulance services. This service falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) coded 93042 provided on March 28, 2021.  You asked the Plan to pay for the rhythm electrocardiogram. 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 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 93042 for the rhythm electrocardiogram is a column II code to column I code 23650. 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 rhythm electrocardiogram (ECG) coded 93042 provided on March 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on August 26, 2021.  You asked the Plan to waive the coinsurance for the denosumab injection. You say that the doctor told you the copayment would be $50. The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for Medicare Part B covered drugs.    You have been asked to pay $246.11, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,230.55 (20% x $1,230.55 = $246.11). The denosumab 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 the denosumab injection provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 37244) provided to the enrollee on April 16, 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 records do not support the services 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, the CPT Code Manual definition of code 37244 is "Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation."  We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the operative report indicates that a fine needle aspiration (FNA) was planned, but was unable to proceed with this procedure, and a computed tomography (CT) was performed. Gel foam pledgets were injected through coaxial needle, without cessation of bleeding. An "angio" was decided. A right PAgram was performed, and a bleeding artery could not be identified. A spine CT was performed, and a feeding vessel was not identified, then coils were placed subcutaneously from the coaxial needle into the AVM nidus. A coaxial needle was removed and repeat PAgram was performed. The documentation does not describe a catheter threaded into a vessel, and coils are released. This procedure cannot be verified as performed.  We looked at this coder'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 pay for surgical services (procedure code 37244) provided to the enrollee on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on  August 30, 2021.  You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says you had already received dental services up to the benefit maximum for the 2021 benefit year.  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 Plan offers a maximum plan benefit coverage amount of $750 per year, which applies to all supplemental (i.e., routine) dental services covered by the Plan. The contract says that you are responsible for any cost above the $750 maximum. The record shows that you met the annual maximum benefit on July 29, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2393) provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve these services. 
You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not adjust insulin dosage based on blood sugar testing results. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission 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 based on the medical records provided 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. Based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Continued care at the skilled nursing facility level appears to be 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve custom fabricated abutments - includes placement (D6057), abutment supported porcelain/ceramic crowns (D6058), and odontoplasty - per tooth (D9971).  You asked the Plan to pre-approve custom fabricated abutments, abutment supported crowns and odontoplasty. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefits.  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 pre-approve custom fabricated abutments - includes placement (D6057), abutment supported porcelain/ceramic crowns (D6058), and odontoplasty - per tooth (D9971).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the cardiology visit, transthoracic echocardiogram, and electrocardiogram to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the cardiology visit, the transthoracic echocardiogram, and the electro-cardiogram. You say that you were told the provider is in-network. The Plan denied your request. The Plan says the provider is out-of-network  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.   The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the cardiology visit, the transthoracic echocardiogram, and the electrocardiogram to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.  You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available records the enrollee appears to have improved with therapy but is still having issues with pain. Further skilled therapy (beyond the now 18 approved visits) at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program after completion of the 18 therapy visits appears appropriate at this point. The records do not document any acute or unstable medical conditions or changes in function which would necessitate further skilled therapy visits beyond the 18 approved visits. No medical notes from the enrollee's treating physician are provided documenting need for additional skilled therapy services beyond the approved 18 visits. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.   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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zubsolv.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.  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 Zubsolv.   Benefits for these services 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 16, 2021.  You asked the Plan to pay for the limited oral exam. You say that you were in pain and you don't understand why the service was denied. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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 the limited oral exam once per plan year.   We looked at the file, and Medicare rules. In this case the Plan has provided documentation showing that a limited oral exam was previously covered on January 12, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the hemodialysis services provided from August 15, 2020, through September 29, 2020.  You asked the Plan to pay for the dialysis services. You say that you have attempted to indicate the presence of the value code 49 several times to the Plan. You submitted a corrected claim with this value in June 2021. The Plan has continued to deny payment based on this value being missing. The Plan denied your request. The Plan says that the hemoglobin or hematocrit needs to be documented on the claim and is missing.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial is based on the absence of value code 48 or 49. The appeal includes evidence that a corrected claim was submitted with value code 49 reported. The rules do not indicate that both would be required. Since the value code has been reported and the hematocrit submitted to the Plan, we find that the denial is not supported in this case. Therefore, we decided that the Plan has to pay for the hemodialysis services provided from August 15, 2020, through September 29, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.