Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on July 1, 2021.  You asked the Plan to waive the coinsurance for the wound care supplies. You say that the home care nurse ordered these supplies without your permission. The Plan denied your request. The Plan says this coinsurance was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for durable medical equipment and supplies.   The enrollee has been asked to pay 20% coinsurance for the wound care supplies. The wound care supplies falls within the durable medical equipment and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on July 1, 2021.   Your complaint about the homecare nurse ordering these supplies without your permission is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve a SNF admission. You say that it is medically necessary based on acute respiratory failure with hypoxia. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.  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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF needs.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on August 26, 2020, to September 2, 2020.  You asked the Plan to pay for the inpatient hospital services. You say that the records provided support the inpatient hospital services as they were billed, and the claim should be paid. The Plan denied your request. The Plan says payment of DRG 453 is not supported, as a review of the records supports DRG 455.  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 a DRG of 453. 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 inpatient hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was a then, 82-year-old male with a history of low back pain who was admitted on August 26, 2020 and underwent L3-L5 facectomies interbody fusion and posterior instrumentation.  On August 30, 2020, he was noted to be lethargic and oriented x 2. There were no abnormal neurological findings noted and no clear cause was documented. There was no specific evidence of encephalopathy. The review has determined that the records did not support the provider's billed DRG 453. The Plan's corrected DRG 455 was appropriate.   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 on August 26, 2020, to September 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an outpatient hospital facility on January 27, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told up front that this would be covered. The Plan denied your request. The Plan says this was covered; however, the cost sharing was charged 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 $350 copayment for outpatient hospital services.   You have been asked to pay a $350 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls 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 the diagnostic colonoscopy you had at an outpatient hospital facility on January 27, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (J7613) provided to the enrollee on April 25, 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 codes in question are not covered by 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 the denied codes is:  J7613:  Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg  A7003:  Administration set, with small volume nonfiltered pneumatic nebulizer, disposable  We find that the denied codes are not supported in the medical record. Specifically, J7613 has a status indicator of "E" which means that it is excluded from the Physician Fee Schedule by regulation. No payment can be made for this code. A7003 has a status indicator of "X" which means that it is statutorily excluded from Medicare payment. 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 the services (J7613) provided to the enrollee on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing services billed with code G0494 for dates of service November 4 - December 30, 2020.  You asked the Plan to pay for the skilled nursing services billed with code G0494. You say that the documentation provided supports that payment should be made on the code in dispute. The Plan denied your request. The Plan says payment is not allowed for this service because the items were billed incorrectly based on the information submitted.  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 G0494 is skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting).  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 skilled nursing services billed with code G0494. Our reviewer says that the criteria for coverage have not been met. Our reviewer found the documentation provided does not include nursing visits to confirm correct billing, and therefore 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 skilled nursing services billed with code G0494 have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing services billed with code G0494 for dates of service November 4 - December 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided on December 21, 2020, January 4, 2021, and January 6, 2021.  You asked the Plan to pay for the additional supplies and materials. You say that this new code was established to report additional practice expenses incurred during a public health emergency and the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate 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, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on December 21, 2020, January 4, 2021, and January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient catheter placement procedure you had at an outpatient hospital facility on March 2, 2021.  You asked the Plan to waive the copayment for the catheter placement procedure. You say that you had this procedure before and they went in through your arm.  You said that because they went in through your groin this time, this was considered surgery.  If you had known of the copayment for this, you would not have had the procedure done. 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 $350 copayment for outpatient surgery and services provided at an outpatient hospital facility.   You have been asked to pay a $350 copayment for the catheter placement procedure. This copayment applies regardless of what you may have paid in the past for similar procedures. 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 outpatient catheter placement procedure you had at an outpatient hospital facility on March 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) service.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that services can be provided at a lower level of care.  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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  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) service.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.   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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on July 2, 2021.  You asked the Plan to pay for the bitewing x-ray (D0274). You say that you thought you had dental coverage. The Plan denied your request. The Plan says the service 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a cerebral vascular accident (CVA), currently in an inpatient rehabilitation facility. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the acute hospital. The enrollee was at close supervision to moderate assist level with functional mobility including gait to 240 feet.  The enrollee required varying assist with activities of daily living.  There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided on September 1, 2020.  You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on September 13, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the services received were not for a routine eye exam but rather an office visit to address dry eye and blurry vision. Eye refractions are not covered.  The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.  We looked at the file and the and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital observation services provided by a participating provider from July 4, 2021, to July 5, 2021.  You asked the Plan to waive the copayment for outpatient hospital observation. You say that you were transferred to the hospital from the emergency room (ER) of a separate medical center. You say you paid the copayment for the ER and feel you should not have a copayment for the services rendered at the hospital. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefit.  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 $350 copayment for each Outpatient Hospital Observation stay.    You have been asked to pay a $205.72 copayment for outpatient hospital observation. The services you received fall within the Outpatient Hospital Observation benefit category. Since the requested copayment is less than the contractual cost-share of $350, you are only responsible for the lesser amount of $205.72. 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 hospital observation services provided by a participating provider from July 4, 2021, to July 5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the gingival irrigation (D4921 x 2), localized delivery of antimicrobial agents (D4381), the periodontal medicament carrier with peripheral seal, maxillary (D5995), and periodontal medicament carrier with peripheral seal, mandibular (D5996) provided on July 10, 2021.  You asked the Plan to pay for the dental services. You say that you were advised by the dental office that the services would be covered. You say that dental office staff refused to show you a print out of what you would owe for the services. You also say that you feel these services should be covered since that was what you were told. The Plan denied your request. The Plan says that the services you received are not listed as covered services.  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 dental services by a contract provider. The file does not show that the Plan provided notice that the dental services would not be covered. Under Medicare rules, this means the dental services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the gingival irrigation (D4921 x 2), localized delivery of antimicrobial agents (D4381), the periodontal medicament carrier with peripheral seal, maxillary (D5995), and periodontal medicament carrier with peripheral seal, mandibular (D5996) provided on July 10, 2021.   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.   Your complaint about the customer service provided by the dental office staff is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.