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

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 19, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you had this procedure in the past with a lower copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for services obtained from a specialist.   You have been asked to pay a $50 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 a specialist office visit provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for diabetic test strips (A4253) and lancets (A4259) provided on December 18, 2020, to January 17, 2021.  You asked the Plan to pay for diabetic test strips and lancets. 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 because the quantity limit for the items at issue has been exceeded.  The Plan must follow Medicare rules. Medicare rules say that that diabetic testing supplies require a date span on all claims submitted to the DME MACs.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic test strips and lancets have not been met. Specifically, the items at issue were provided as a 90-day supply but billed with a date span of one month. Payment for the items at issue would require submission of a corrected claim to the Plan. Therefore, we decided that the Plan does not have to pay for diabetic test strips (A4253) and lancets (A4259) provided on December 18, 2020, to January 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for mechanical traction (97012) chiropractic manipulation of the extra-spinal regions (98943) electrical stimulation (G0283) provided September 3, 2021.  You asked the Plan to pay for the chiropractic services. You say that please see attached medical notes for medical necessity. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction (97012) chiropractic manipulation of the extra-spinal regions (98943) electrical stimulation (G0283) provided September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the perfusionist services (86891, 99190, 99191, P9022) provided on June 24, 2021.  You asked the Plan to pay for the perfusionist services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim has denied correctly based on Medicare billing regulations.  The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.   We looked at the file and Medicare rules. The services at issue were provided while the enrollee was an inpatient and must be billed through the hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services (86891, 99190, 99191, P9022) provided on June 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99324) provided on September 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the treatment rendered was medically necessary per the physician that provided the service. The Plan denied your request. The Plan says the service was rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.

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 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 the domiciliary or rest home visit (99324) provided on September 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient acute care services provided from July 8, 2021, to August 9, 2021.
You asked the Plan to waive the copayment for the inpatient acute care services. You say that the services should be covered and considered continuous care. The Plan denied your request. The Plan says the cost-sharing applied correctly since you were transferred to a new facility, the cost-sharing was reset.
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 per day for days 1-7 for Inpatient hospital care.
You have been asked to pay a $1,575 copayment for seven days of inpatient acute care services ($225 x 7 = $,1575). 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 inpatient acute care services provided from July 8, 2021, to August 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound provided on October 6, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 76705 was billed with code 93976. We find that CPT code 76705 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the face down recovery system and set up provided on May 18, 2021, and June 7, 2021.  You asked the Plan to pay for the face down recovery system and set up. You say that the item is 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 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. CMS has confirmed that these devices are statutorily noncovered because they do not fall within a Medicare benefit category. These types of devices are considered "precautionary devices" and also can be used for purposes other than the treatment of an illness or injury. The denial is a coverage denial, not a medical necessity denial. Therefore, we decided that the Plan does not have to pay for the face down recovery system and set up provided on May 18, 2021, and June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on August 12, 2021.  You asked the Plan to pay for code 99153. 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the out-of-network (OON) provider on October 12, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99310) rendered by the out-of-network (OON) provider on October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a walker provided on July 23, 2021.  You asked the Plan to waive the coinsurance for a walker. You say that you were never informed of the coinsurance on the walker and that it was fully covered. The Plan denied your request. The Plan says the correct coinsurance was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered benefits. The total amount allowed for the walker was $94.61 with the coinsurance being $18.92 ($94.61 total cost x 20% coinsurance).    You have been asked to pay a 20% coinsurance for the walker. A walker falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a walker provided on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lesion destruction (17004) provided on June 22, 2021.  You asked the Plan to pay for the lesion destruction (17004). You say that CPT code 17004 is a separate charge and not to be included. The Plan denied your request. The Plan says procedure 17004 billed on June 22, 2021, is included within the global surgery package of procedure 11602 billed on June 15, 2021.  The Plan must follow Medicare rules. Medicare rules say that Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lesion destruction (17004) have not been met. Specifically, a modifier was not billed to indicate this was an unrelated service. Therefore, we decided that the Plan does not have to pay for the lesion destruction (17004) provided on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the perfusion services provided on August 23, 2021.  You asked the Plan to pay for the services provided. You say that the service was arranged directly with the surgeon and facility. The Plan denied your request. The Plan says payment would be included in the facility payment.  The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.  We looked at the file and the rules. The records show that the enrollee was receiving inpatient care at the time the services at issue were provided. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the perfusion services provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rectum procedure (45999) provided on May 27, 2021.  You asked the Plan to pay for the rectum procedure (45999). You say that per the coder review the claim is billed correctly. You say that the medical records should be reviewed, and the claim should be processed for payment. The Plan denied your request. The Plan says the records do 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 45999 is unlisted procedure, rectum.     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 rectum procedure (45999). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the procedure report does not describe an unlisted procedure of the rectum, therefore this procedure cannot be verified.  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 rectum procedure (45999) have not been met. Therefore, we decided that the Plan does not have to pay for the rectum procedure (45999) provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient ophthalmologist services (92134, 67028) provided from January 4, 2021, to July 6, 2021.  You asked the Plan to waive the copayment for the outpatient ophthalmologist services. You say that the services should be covered as they would cause financial hardship. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Outpatient hospital services.     You have been asked to pay a $1,650 copayment for six separate outpatient ophthalmologist service visits ($275 x 7 = $1,650). Outpatient ophthalmologist services fall within the Outpatient hospital 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 outpatient ophthalmologist services (92134, 67028) provided from January 4, 2021, to July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for established patient, routine ophthalmological examination including refraction (S0621) provided September 16, 2021.  You asked the Plan to pay for the vision services. You say that please reimburse you the $100. The Plan denied your request. The Plan says proof of payment is needed for reimbursement.  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 find that CPT code S0621 is not supported in the medical record. Specifically payment is not allowed because proof of payment is needed for reimbursement. The Plan made 3 attempts to obtain proof of payment without success. Based on this information, we decided that Medicare rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for established patient, routine ophthalmological examination including refraction (S0621) provided September 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xifaxan.  You asked the Plan to pre-approve Xifaxan. The Plan denied your request. The Plan says Xiafaxan to be administered at home is not covered under the Part B 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 Xifaxan.     Benefits for Xifaxan 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 subsequent nursing facility care (99309) provided on July 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the nursing facility care. You say that the treatment the enrollee received was medically necessary and the physician provided a statement of medical necessity and medical records to justify the reason for the enrollee's stay. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 subsequent nursing facility care (99309) provided on July 12, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834, 90837) provided on September 5 and September 10, 2021.  You asked the Plan to pay for psychotherapy services. You say that your benefits cover in- and out-of-network services. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834, 90837) provided on September 5 and September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires daily physician oversight, nursing, medication adjustments, and rehab therapy. The Plan denied your request. The Plan says the enrollee is receiving appropriate acute care and does not require transfer.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our physician reviewer found that in this case, the enrollee was admitted for symptomatic bradycardia during weaning trials and was found to require a pacemaker. The record indicates that the enrollee is also anemic. It has not yet been determined whether the enrollee can be weaned now that the pacemaker is placed. The enrollee requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.