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

We decided that the Plan does not have to pay for the medical services rendered on February 19, 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 procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for anticoagulation management services you
received at your cardiologist's office from January 14, 2021, to April 22, 2021.
You asked the Plan to waive the cost sharing for the anticoagulation management services. You say that you
received the same services on each date, but the amounts due are different. You would like these reviewed and
adjusted. The Plan denied your request. The Plan says you were charged the appropriate cost sharing. The Plan
says that since the allowed amounts for these services are less than your copayment obligation, you are
responsible for the full allowed 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 $35
copayment for services with a specialist.
You have been asked to pay a $35 copayment for the anticoagulation management services. The allowed rate
for these services is based on the Medicare fee schedule, which can change throughout the year. That is why
for the same services, the allowed amount may differ between dates of service. 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 cost sharing for anticoagulation management services you received at your cardiologist's office
from January 14, 2021, to April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services (11043, 99310, 11042, 11044) provided on June 9, 2021.
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available. The services were not emergent.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for wound care services (11043, 99310, 11042, 11044) provided on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 1, 2020, to March 26, 2020, billed with Health Insurance Prospective Payment System Code (HIPPS) code GAPF1.
You asked the Plan to pay for the SNF services as billed. You say that this was correctly billed based on the assessments submitted. The Plan denied your request. The Plan says the documentation does not support the nursing CMG component, surgical wound care. As such, the Clinically complex category is not supported.
The Plan must follow Medicare rules. Medicare rules say that payment for SNF services is made based on the reported HIPPS code which is determined based on the calculated case-mix group for each SNF discipline. We looked at the file and Medicare rules. The Plan has indicated that HIPPS code GAPF1 is not supported, stating that GAXF1 is correct. The Minimum Data Set (MDS) assessment included in the appeal request clearly identifies the case-mix group for nursing services as PBC1. In order to qualify for payment of GAPF1, the case mix would have to be CBC1. This would require the presence of conditions under Category: Clinically Complex. We find that none of these conditions are present. The documentation supports the reported CMG of PBC1. As such, the third digit of P in the reported HIPPS code is not appropriate. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 1, 2020, to March 26, 2020, billed with Health Insurance Prospective Payment System Code (HIPPS) code GAPF1.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the limited oral exam (D0140) provided on June 17, 2021.
You asked the Plan to pay for the limited oral exam. You say that this should be paid. The Plan denied your request. The Plan says that payment was already made for one limited oral exam during the year. As such, the exam on 6/17/2021 is correctly denied.
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 that the limited oral exam cannot be paid on June 17, 2021 because the maximum for this procedure was paid for the year. However, the Plan did not forward evidence to show that one unit of D0140 was paid during the year. Without that evidence, we find that the denial is not supported. Therefore, we decided that the Plan has to pay for the limited oral exam (D0140) provided on June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided from June 1, 2021, to June 5, 2021.
You asked the Plan to waive the copayment for inpatient care. You say that you did not know you would be
responsible for this copayment. The Plan denied your request. The Plan says this claim was processed
correctly, and your copayment was assessed in accordance with your contract.
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 $290
copayment for each of the first seven days of an inpatient hospital stay.
You have been asked to pay a $1,160 copayment for a four-day hospital stay ($290 x 4 = $1,160). 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 inpatient hospital admission and services provided from June 1,
2021, to June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213), the duplex scan of the extremity veins including responses to compression and other maneuvers; complete bilateral study (93970), and the duplex scan of the lower extremity arteries or arterial bypass grafts; complete bilateral study (93925) rendered by the out-of-network (OON) provider on September 27, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization. Additionally, the services provided were not urgent nor emergent.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99213), the duplex scan of the extremity veins including responses to compression and other maneuvers; complete bilateral study (93970), and the duplex scan of the lower extremity arteries or arterial bypass grafts; complete bilateral study (93925) rendered by the out-of-network (OON) provider on September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on May 20, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you believe the charges are excessive and you did not get a report after these labs. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you are only responsible for the $20 copayment for the labs.
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 $20 copayment for lab services. You have been asked to pay a $20 copayment for the lab services. 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 lab services you had on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral cancer screening (D0431) provided on May 26, 2021.
You asked the Plan to pay for an oral cancer screening. You say that the claim at issue should have been paid by the Plan. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an oral cancer screening (D0431) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound closure by adhesive rendered on March 25, 2020. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code and identifies whether the service described by the HCPCS code is paid under the OPPS. 
 
We looked at the file and Medicare rules. The file shows that billed procedure code G0168 (wound closure by 
adhesive) has an OPPS status indicator of B and is not recognized for payment. 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 pay for the wound closure by adhesive rendered on March 25, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
June 3, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that your doctor told you to go to the ER
due to readings your on blood work. You said that the blood work results were incorrect, so you should not
have to pay the copayment. 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 $90
copayment for emergency room visits.
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason
for the ER visit. 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 emergency room (ER) visit
you had on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided March 22, 2021.
You asked the Plan to pay for the core buildup. You say that the service should be covered. The Plan denied your request. The Plan says this service is not covered because the primary treatment (crown) has not been approved.
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 core buildup when performed together with a crown. We looked at the file and Medicare rules. In this case the record shows that the core buildup has not been performed together with an approved crown. Based on this information, we decided that the Plan's rules for
coverage of the core buildup have not been met. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided March 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95908, 95885) provided on March 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.
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 codes 95908 and 95885 have a bundled relationship with code 95861 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (95908, 95885) provided on March 22, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of excessive skin and tissue beneath the skin of abdomen (15830).
You asked the Plan to pre-approve the removal of excessive skin and tissue beneath the skin of abdomen. You say that this requested surgery is medically necessary. The Plan denied your request. The Plan says the requested procedure is not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the removal of excessive skin and tissue beneath the skin of abdomen. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had massive weight loss after bariatric surgery. The record does not indicate that the enrollee has intertrigo not responsive to conservative treatment. The record does not indicate the extent of the pannus. The requested service appears cosmetic in nature. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. 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 removal of excessive skin and tissue beneath the skin of abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of excessive skin and tissue beneath the skin of abdomen (15830).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 9, 2020 to November 11, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee had severe osteoarthritis of the left knee and was electively admitted for a left total knee arthroplasty. The enrollee underwent planned surgery without any complication. The enrollee was observed in post-anesthesia unit and transferred to orthopedic floor. The enrollee's post- operative course was uncomplicated. The enrollee's pain was controlled and started physical therapy. The enrollee was discharged home on November 11, 2020 with home health. The review has determined that the record showed that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided November 9, 2020 to November 11, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided on June 1, 2020, through June 11, 2020.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the HIPPS code billed.
The Plan follows Medicare rules. Medicare rules say that SNF Part A inpatient services are paid under a prospective payment system (PPS) which involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. 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 the documentation submitted does not support the reported diagnosis of malnutrition. Our physician reviewer found the enrollee's Body Mass Index is ideal. There is no documentation of weight loss of 5% or more in the last month, or loss of 10% in the last 6 months. The enrollee was noted to be on appropriate nutrition interventions. 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. Specifically, the HIPPS code billed is not supported because the documentation does not support a diagnosis of Malnutrition. Therefore, we decided that the Plan does not have to pay for the SNF services provided on June 1, 2020, through June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided from June 11, 2021, to June 24, 2021.
You asked the Plan to pay for the chiropractic manipulative treatment. You say that this procedure has been helpful for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We looked at this physician's review, the file, and Medicare rules. In this case, the chiropractic care was maintenance care. This is specifically excluded from coverage under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chiropractic manipulative treatment have not been met.
Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided from June 11, 2021, to June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical X-rays (D0220, D0230) provided on April 21, 2021.

You asked the Plan to pay for intraoral-periapical X-rays. You say that the services at issue were part of preventive services. The Plan denied your request. The Plan says the services at issue are not a covered benefit.

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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral-periapical X-rays (D0220, D0230) provided on April 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that the enrollee is stable on the current medication. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Trulicity.
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights