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

We decided that the Plan does not have to waive the deductible for a skin biopsy and testing provided on August 26, 2021.

You asked the Plan to waive the deductible for the biopsy and testing. You say that you thought you would only be responsible for a $10 specialist copayment. The Plan denied your request. The Plan says the correct amount was applied to 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 certain items and services. 

The item or service you asked the Plan to waive the deductible for falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the biopsy and testing was received on August 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a skin biopsy and testing provided on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673).

You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCDs have not been met. Specifically, these items are not a covered benefit of Medicare or the 
Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for pneumatic compression devices (E0675, E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) and for an x-ray of the hip/pelvis (73502) provided on June 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit and for an x-ray of the hip/pelvis. You say that your interpretation of the state office of the insurance commissioner is not to deny services from an Indian health care provider for a fully insured group plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they had also determined that these services are not urgent or emergent, nor were they approved in advance.

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 an office visit (99214) and for an x-ray of the hip/pelvis (73502) provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on May 18, 2021.

You asked the Plan to pay for the neuromuscular junction testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that only specific diagnosis codes billed with code 95937 are covered. 

We looked at the file and Medicare rules. Medicare rules say that only specific diagnosis codes billed with code 95937 are covered. Any code not listed is not covered. Diagnosis code M47.12 (Other spondylosis with myelopathy, cervical region) is not listed as a covered diagnosis code for this procedure rendered. Based on this information, we decided that Medicare rules for coverage of the neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on May 18, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his reduced endurance level. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 6, 2021.
You asked the Plan to pay for lab tests. You say that at this time there is no contractual agreement in place
which dictates that these codes are included in the dialysis rate. The Plan denied your request. The Plan says
the denial of payment for these services is correct, because these tests are included in the end-stage renal
disease (ESRD) prospective payment system (PPS) rate paid to the dialysis facility and are not separately
payable.
The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for
the treatment of ESRD are included in the ESRD PPS and are not separately payable.
We looked at the file and Medicare rules. These lab services are among the lab services which are consolidated
for billing in the ESRD PPS and are not separately payable. Based on this information, we decided that
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have
to pay for laboratory testing provided on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on August 25, 2021

You asked the Plan to pay for the consultation. You say that this should have been covered under your medical insurance. The Plan denied your request. The Plan says the documentation submitted provides no additional information that justifies this request.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on August 25, 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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.
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 pay for out of network medical services provided to the enrollee on June 23, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 out of network medical services provided to the enrollee on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the complete upper denture (D5110) and partial lower denture (D5214) provided on July 7, 2021.

You asked the Plan to pay an additional amount for the dental items. You say that you were told that you had full coverage for dentures. You also say that you were not informed about the 30% coverage until after you had the work done. The Plan denied your request. The Plan says there is a 70% coinsurance for dentures received in network.

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 and dentures are listed as covered, there is a 70% coinsurance that applies. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the complete upper denture (D5110) and partial lower denture (D5214) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services coded 99495 provided on July 10, 2020.
You asked the Plan to pay for the transitional care management services. 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, the CPT Code Manual definition of code 99495 is transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge.
We find that CPT code 99495 is not supported in the medical record. Specifically, this service is only eligible for reimbursement one time during the 30 days after a hospital stay. The documentation shows that the enrollee previously received these services on July 3, 2020. The records do not support an additional hospital stay; therefore, the additional claim for these services provided on July 10, 2020 is not payable. Based on this information, we decided that Medicare rules for coverage of the transitional care management services have not been met. Therefore, we decided that the Plan does not have to pay for the transitional care management services coded 99495 provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 12, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be charged a copayment for a phone call. 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). Your contract with the Plan clearly says that you must pay a $40 copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $40 copayment for the specialist office visit. The specialist office 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 the specialist office visit provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a general health panel (80050) provided on April 8, 2021.

You asked the Plan to pay for a general health panel. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. 

You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel (80050) provided on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, home with home health services or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0230) and extraction (D7210) provided on July 19, 2021.
You asked the Plan to pay for the x-ray and extraction. You say that you had a broken tooth. You say that the dental office had 1 dentist that was in network. You also say that your tooth ended up being extracted. The Plan denied your request. The Plan says the provider in this case was not in network on the date of service in this case. The Plan also says that dental services received out of network are not covered.
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, dental services received out of network are not among those covered under this benefit. Additionally, the record shows that the provider in this case did not become in network with the Plan until September 2021. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0230) and extraction (D7210) provided on July 19, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for lesion destruction (17110) provided on December 28, 2020.

You asked the Plan to pay for lesion destruction. You say that this is supported in the records. The Plan denied your request. The Plan says that this was not linked to an appropriate diagnosis.

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 rules also say that diagnosis codes that support medical necessity for procedure code 17110 include L82.1 and L72.0. 

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 states that this service was not linked to an appropriate diagnosis, but the Plan has not submitted documentation such as the original claim form to show what diagnosis codes were billed. The submitted medical records show that the enrollee was documented to have covered diagnoses L822.1 and L72.0. Without documentation such as the claim form, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for lesion destruction (17110) provided on December 28, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture therapy (97139) provided on April 19, 2021

You asked the Plan to pay for the acupuncture therapy. 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.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the diagnosis code billed was not for treatment of 
chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture therapy 
(97139) provided on April 19, 2021