Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on July 2, 2021.  You asked the Plan to pay for hearing aids. You say that you cannot hear with cheaper hearing aids, and you have to invest in the more expensive ones. The Plan denied your request. The Plan says hearing aids ordered through providers other the Plan hearing provider are not covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a Plan hearing network provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from a Plan hearing network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the End Stage Renal Disease (ESRD) services provided on March 12, 2020, through May 30, 2020.

You asked the Plan to pay for the ESRD services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim is missing information.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ESRD services have not been met. Specifically, this claim has not been billed with the required modifier for revenue code 0821. Therefore, we decided that the Plan does not have to pay for the End Stage Renal Disease (ESRD) services provided on March 12, 2020, through May 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device.  You asked the Plan to pay for a pneumatic compression device. You say that prevention of venous thromboembolism through the active use of pneumatic compression has been the standard of care for over 20 years. The Plan denied your request. The Plan says the denial of payment for this device is correct, because a pneumatic compression device is not covered by Medicare for this purpose.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) 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 PCD have not been met. Specifically, this item is 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 a pneumatic compression device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue expander replacement provided on June 22, 2021.

You asked the Plan to pay for the services provided. You say that authorization was obtained to achieve reasonable breast symmetry. 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 CPT code. 

In this case, the CPT Code Manual definition of code 11970 is replacement of tissue expander with permanent implant. We find that CPT code 11970 was billed with code 19325. CPT code 11970 may be eligible for payment when billed with this code pair. The claim does not show 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 tissue expander replacement provided on June 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services.  You asked the Plan to pre-approve the services. You say that you struggle with anxiety when you are alone. The Plan denied your request. The Plan says the skills of the nurse are not needed for general health assessment and medication/nutrition management.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you do not have documented skilled nursing needs, such as IVs, complex wound care, new ostomy, etc. As such, the requested ongoing home health skilled nursing services are not 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 pre-approve home health services.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to hold you harmless for the bone density scan (77081) provided on March 16, 2020.  You asked the Plan to hold you harmless for the bone density scan. You say that you would like reconsideration because you believed this issue had been taken care of between the provider and the Plan. The Plan denied your request. The Plan says that the provider did not bill this claim with an appropriate diagnosis code.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the bone density scan by a contract provider. The file does not show that the Plan provided notice that the bone density scan would not be covered. Under Medicare rules, this means the bone density scan is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the bone density scan (77081) provided on March 16, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible applied to lab services you had on July 22, 2021.  You asked the Plan to waive the deductible applied to the lab services. You say that you have never had to pay for lab services before. The Plan denied your request. The Plan says you were assessed this deductible correctly.  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 a $250 deductible which applies to lab services.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services were received on July 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied to lab services you had on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 9, 2021.  You asked the Plan to pay for the dental service. You say that you were referred to a dental clinic due to a mysterious lump. You say that you were seen by a medical specialist. You say that you were advised there was no billing code for that. You also say that this should be processed as medical. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered dental service. The Plan also says that this claim has been sent to the medical department for review under a separate case number.  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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services you received on February 4, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that the hospital requested the ambulance, not you. You said that you should not have to pay anything. 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 $275 copayment for ambulance services.     You have been asked to pay a $275 copayment for the ambulance services. This copayment applies regardless of who requests the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services you received on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services rendered on July 3, 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 are not covered.

The Plan must follow Medicare rules. The rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported. 

We looked at the file and Medicare rules. The file shows that billed procedure code 99238 (hospital discharge day management) was reported on the same day by the same provider as code 99239 (hospital discharge day management, more than 30 minutes). Code 99238 is therefore not also payable. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services rendered on July 3, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that your life and health is in danger. The Plan denied your request. The Plan says that that the services you require can safely be received at a different setting.  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 care. Our reviewer says that that SNF care is medically reasonable and necessary for the enrollee. You do have documented skilled nursing needs. You need to receive 100% of your nutrition via enteral feeds until at least your first follow-up visit. Teaching is needed to assure that you, or an appropriate caregiver, can manage your feedings. Documentation of such teaching and competence of same is not yet provided. You do not have documented skilled therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare criteria for SNF care.  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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit services provided on May 31, 2021, to June 15, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 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 home visit services provided on May 31, 2021, to June 15, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health aide services provided on November 10, 2020.  You asked the Plan to pay for the services provided. You say that the documentation supports medical necessity. The Plan denied your request. The Plan says this code is not valid for Medicare.  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 G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes. We find that CPT code G0156 is an excluded code. No payment may be made under the physician fee schedule. 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 home health aide services provided on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from June 1, 2021, to June 3, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not feel that you should be responsible for this 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 $343 copayment per day for days 1-4 for inpatient hospital services.   Records show that you were in the hospital for two days. You were charged a $343 copayment for each day, for a total of $686.  This copayment applies regardless of the reason for the hospital stay. 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 hospital services you received from June 1, 2021, to June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolonged evaluation and management services (99417) provided on April 9, 2021.  You asked the Plan to pay for prolonged evaluation and management services. You say that this is a payable code. The Plan denied your request. The Plan says this code is not valid.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99417 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services.  Based on this information, we decided that Medicare rules for coverage of prolonged evaluation and management services have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management services (99417) provided on April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the x-ray of the spine you had on September 13, 2021.  You asked the Plan to waive the copayment for the x-ray of the spine. You say that this billing is part of the Dexa scan that is covered every two years.  You stated that you had this same procedure done two years ago at the same center and it was covered completely by your previous insurer. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($23.89) is 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 x-rays in a specialist's office.   You have been asked to pay a $35 copayment for the x-ray of the spine. You were not charged any cost sharing for the bone density scan you had on that same date of service. This cost sharing applies regardless of what you may have paid with a previous insurer.  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 x-ray of the spine you had on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on August 3, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that this visit was medically necessary. The Plan denied your request. The Plan says the benefit limit for D0140 has already been exhausted this calendar year.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral evaluation once per calendar year.  We looked at the file and Medicare rules. Evidence was provided that shows a limited oral evaluation was provided on July 27, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation has already been exhausted this calendar year. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on August 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for a psychotherapy visit (90837) provided on July 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a psychotherapy visit. You say that you thought this provider was in-network. The Plan denied your request. The Plan says this was not authorized.  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 a psychotherapy visit (90837) provided on July 29, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Partially Favorable

 We decided that the Plan has to reduce the cost-sharing charges for a SNF stay. We decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.   You asked the Plan to waive the copayment for a SNF stay. You say that you are unable to walk and required the care and are being charged $28,000 because the Plan is not paying. The Plan says that the claims were processed correctly and you are being charged the correct amount.  We decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $2,392 to $2,208.   Your contract with the Plan clearly says that you must pay a $0 copayment for days 1-20 and a $184 copayment for days 21-100 for a SNF stay.  The Plan says that you must pay a copayment for 13 SNF days. However, you cannot be charged a copayment for the day you are discharged. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $2,392, to $2,208.   We also decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.   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 $0 copayment for days 1-20 and a $184 copayment for days 21-100 for a SNF stay.   You had a SNF stay from April 16, 2021, to May 18, 2021. You are not being charged a copayment for days 1-20 (April 16, 2021, to May 5, 2021). You are responsible to pay a $184 copayment for days 21-32 (May 6, 2021, to May 17, 2021). The total amount you owe is: $184 (copayment) x 12 (SNF days) = $2,208. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.   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.