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

We decided that the Plan does not have to waive the copayment for the upper gastrointestinal (GI) endoscopy provided by a network facility on September 2, 2021
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that this service should be covered because your colonoscopy was covered by the Plan. 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 $225 copayment for each in-network Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $225 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including 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 the upper gastrointestinal (GI) endoscopy provided by a network facility on September 2, 2021.
Please note that this decision is only regarding the claim for date of service September 2, 2021. Please contact the Plan regarding any appeals you may have for other dates of service.
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 does not meet criteria.

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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on March 29, 2021 to April 27, 2021.

You asked the Plan to pay for the compression stockings. You say that the items were medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on March 29, 2021 to April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig (A9282), provided on September 23, 2021.
You asked the Plan to pay for the wig. You say that you need this item. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the wig (A9282), provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on March 17, 2021.

You asked the Plan to pay for the office visit. 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 service 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 99212 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. 

We find that CPT code 99212 is not supported in the medical record.

Specifically, the record submitted clearly indicates that an in-person evaluation was not rendered on the billed date of service and that the member was there for a blood-draw. The documentation submitted does not support the service billed. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99212) provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 14, 2021.

You asked the Plan to pay for the dental service. You say that you were not informed this service was only covered once every 3 years. You say that you never knew what type of exam the provider would do. You also say that this should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan also says that the frequency limit was exceeded.

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 the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on June 1, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), intraoral - periapical each additional radiographic image (D0230) and panoramic radiographic image (D0330) provided October 11, 2021.
You asked the Plan to pay for the comprehensive oral exam, additional intraoral x-ray and panoramic x-ray. You say that you saw a new provider because you were dissatisfied with your previous provider. The Plan denied your request. The Plan says you have exceeded the frequency limit for these services.
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 one comprehensive or periodontal exam every three years, one intraoral x-ray per calendar year and one full mouth or panoramic x-ray every five years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam and full mouth x-rays were previously covered on October 2, 2020. The Plan also provided documentation showing that an intraoral x-ray was covered on October 11, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam, additional intraoral x-ray and panoramic x-ray have been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150), intraoral - periapical each additional radiographic image (D0230) and panoramic radiographic image (D0330) provided October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided October 26, 2021.
You asked the Plan to pay for the intraoral x-ray and emergency diagnostic exam. You say that you still have remaining balance in your dental allowance, so you do not understand why these services are not covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for these services.
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 intraoral x-ray once per calendar year and emergency diagnostic exam or periodic exams twice per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic oral exam was covered on January 19, 2021, and July 20, 2021. Intraoral x-rays were previously covered on July 20, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the intraoral x-ray and limited oral exam have been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140) provided October 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90834) provided September 1, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says service not supported without required documentation.

The Plan must follow Medicare rules. The rules say that if the patient consents, you must attempt to consult their attending or primary care physician about provided services and either document consent or declination date to consultations and date of consultations in patient's medical record. If consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. 

We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the services at issue. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90834) provided September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on August 18, 2021.
You asked the Plan to pay for the services. You say that the claim denied incorrectly. The Plan denied your request. The Plan says there is a missing/incomplete/inappropriate place of service.
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 71045 is "Radiologic examination, chest; single view." 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 documentation does not include a radiology report to verify service was performed, also, documentation supports hospital claims for dates of service July 30, 2021 through August 26, 2021. Services provided to an inpatient would be reimbursed to the provider by the hospital. In this case the wrong place of service was reported. 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 radiology services provided to the enrollee on August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray exam of the shoulder (73030) provided on July 8, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an x-ray exam of the shoulder. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained prior to the services being rendered.

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 x-ray exam of the shoulder (73030) provided on July 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on April 13, 2021.
You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator of B.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the special anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the special anesthesia service (99100) provided on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 22, 2021, to May 28, 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 DRG 190 is not supported, while DRG 191 may be supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 190 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found chronic obstructive pulmonary disease (COPD) with MCC with secondary acute respiratory failure with hypoxia was reported and requested. COPD with CC is more appropriate as there was insufficient evidence of respiratory failure. The respiratory rate was less than 30, SpO2 was above 90%, and there was no use of accessory muscles or changes in mental status as required. DRG 191 is more appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 22, 2021, to May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the bladder instillation of anticarinogenic agents provided by a network facility from August 27, 2021, to October 15, 2021.

You asked the Plan to waive the copayments for the bladder instillations. You say that you do not agree with your responsibility on the claims. 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 $250 copayment for each outpatient hospital visit.

You have been asked to pay a $250 copayment for the bladder instillations on each date of service. The bladder instillation falls within the "Outpatient surgery, including services provided at hospital 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 copayments for the bladder instillation of anticarinogenic agents provided by a network facility from August 27, 2021, to October 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have a skilled need.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that you were admitted to the acute care hospital for lower extremity cellulitis. You are at a supervision assist level for rolling sitting up, lying down, and standing up. You are at standby assist for transfers, and contact guard assist for walking. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin 30 mg tablet.
You asked the Plan to pre-approve Oxycontin. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Oxycontin 30 mg tablet.
Benefits for Oxycontin 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 pay for sacroiliac joint radiofrequency ablation provided to the enrollee on May 6, 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 services do not meet the coverage requirements.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is considered experimental and investigational. Therefore it was 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for sacroiliac joint radiofrequency ablation provided to the enrollee on May 6, 2021.