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

We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 19, 2020, by a non-participating provider.
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The Plan denied your request. The Plan says it was determined that there are no records of a prior authorization being obtained from the enrollee's primary care physician (PCP) to this non-participating provider prior to services being rendered on August 19, 2020
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 the medical services provided to the enrollee on August 19, 2020, by a non-participating provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 70 additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that you require these trips to get to dialysis treatments. The Plan denied your request. The Plan says no further trips can be approved beyond the 48 trip limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you will have exhausted the Plan maximum benefit for coverage of routine transportation after the 48th trip is used. There is no provision in the contract which would require the Plan to extend this benefit. Therefore, we decided that the Plan does not have to pre-approve 70 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would like approval to see this provider because of established care. The Plan denied your request. The Plan says these services can be provided in-network.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided 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 outpatient visit provided by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says criteria for obtaining out-of-network coverage were not met.
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 the outpatient visit provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided by an out-of-network provider.

You asked the Plan to pay for chiropractic services. You say that you didn't know the referral expired. The Plan denied your request. The Plan says a valid referral is required prior to obtaining services.

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 chiropractic services provided by an out-of-network provider.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for respiratory failure and COVID-19 pneumonia. The complexity of her nursing, medical, and rehabilitation needs does not require an acute hospital stay with an interdisciplinary approach to rehabilitation care. She was discharged home with home health services. Her medical problems are stable and she has no complex nursing or rehabilitation needs. She does not require an intensive therapy program in an IRF. There is not a reasonable expectation that the enrollee 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says close medical supervision is not needed.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for left knee replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) and crown (D2750) provided on October 26, 2020.
You asked the Plan to pay for the post and core and crown. You say that you were under the impression that these services would be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 prefabricated post and core in addition to crown (D2954) and crown (D2750) provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on October 19, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you were told this charge would be waived. The Plan denied your request. The Plan says this processed 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 $10 copayment for physician services. You have been asked to pay a $10 copayment for an office visit, which is a physician service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit (99213) provided on October 19, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the punch biopsy of the skin (11104).

You asked the Plan to waive the copayment. You say that this service was provided at a physician's office, not at the outpatient hospital facility. The Plan denied your request. The Plan says that the copayment was applied correctly to the service 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 does not say in clear and accurate terms that an enrollee should expect to pay a copayment for Medicare-covered outpatient surgery or other services when provided at a physician's office that is off the campus of an outpatient hospital.

We looked at your contract with the Plan. We did not see where the contract says that enrollees must pay a copayment for Medicare-covered outpatient surgery or other services when provided at a physician's office that is off the campus of an outpatient hospital. The Plan contract does not clearly say that a copayment would apply to this service as it was not provided at the outpatient hospital. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the punch biopsy of the skin (11104).

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal (45385) provided on October 22, 2020
You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that the procedure should be covered in full as a standard colonoscopy. The Plan denied your request. The Plan says this procedure was billed with a surgical code and medical records were provided that support that a polyp was removed during this procedure. Since there was surgical diagnostic work performed during this colonoscopy, the outpatient surgery copayment applies.
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 $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for the colonoscopy with lesion removal. Because the colonoscopy included lesion removal, this service falls within the outpatient surgery 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 colonoscopy with lesion removal (45385) provided on October 22, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on June 30, 2020.
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 claim was recoded as CPT 99284, which is more appropriate.
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity." We asked our coding 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 coding reviewer found the emergency room visit supports a comprehensive history and physical exam, however, the medical decision making supports a low level of risk with labs and iv fluids. Therefore, the appropriate code to report is CPT 99284. 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 emergency department services (CPT 99285) provided to the enrollee on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit.

You asked the Plan to waive the copayment for office visit. You say that this visit was scheduled as a physical and you usually do not have a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $25 copayment for primary care office visit. This visit included an Annual Wellness Visit, which has been covered with no cost-sharing responsibility for. This visit also included non-routine services, so an office visit with copayment was billed in addition to the annual wellness visit.

You have been asked to pay $25 copayment for office visit. 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 an office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy (97014), hot or cold packs therapy (97010), and the neuromuscular reeducation (97112) provided on July 10, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy (97014), hot or cold packs therapy (97010), and the neuromuscular reeducation (97112) provided on July 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97010, 97110, 97140, 97014) provided from July 28, 2020 to September 1, 2020.
You asked the Plan to waive the copayment for the physical therapy. You say that you received a notice that the copayments for office visits would be waived from July 1, 2020, until December 31, 2020. The Plan denied your request. The Plan says the waiver is valid for office visits, but physical therapy is an outpatient rehabilitation service separate from an office visit. The waiver does not apply to outpatient rehabilitation services. Therefore, the copayment amount still applies.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient rehabilitation services. You have been asked to pay a $20 copayment for each physical therapy session. Physical therapy falls within the outpatient rehabilitation 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 physical therapy services (97010, 97110, 97140, 97014) provided from July 28, 2020 to September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified DME (E1399) and an unspecified procedure (99199) received on October 13, 2020.
You asked the Plan to pay for unspecified DME and an unspecified procedure. You say that the requested DME item helps a lot with your back. The Plan denied your request. The Plan says rules for payment have not been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested DME and services have not been met. Specifically, the items/services at issue were provided by a provider that appears to not be certified for Medicare. The provider at issue did not come up on the Medicare.gov search for DME suppliers serving the enrollee's area. There was no documentation supplied by the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does not have to pay for unspecified DME (E1399) and an unspecified procedure (99199) received on October 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided December 7, 2019, through December 29, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that you believe you were charged an out-of-network copayment instead of an in-network copayment for the services. The Plan denied your request. The Plan says the copayment was applied 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 $0 copayment per day for days 1 to 20 of an in-network SNF stay. You are then responsible for a $172 copayment per day for days 21-60 for in-network SNF care. You have been asked to pay a total of $344 ($172 copayment each for days 21 and 22 of your SNF stay). This service falls within the Skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) services provided December 7, 2019, through December 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided to the enrollee on September 21, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS codes V2627, V2629, V2623, V2628, V2626, V2624 is not supported in the medical record. Specifically, there is no valid physician order to verify these codes. 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 vision care services provided to the enrollee on September 21, 2020.