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

We decided that the Plan does not have to pay for an office visit (99214), an eye examination with photos (92250), and an eye refraction (92015) provided on January 19, 2021.
You asked the Plan to pay for an office visit, an eye examination with photos, and an eye refraction. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider with no referral. The services were not urgent, emergent, or approved in advance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an office visit, an eye examination with photos, and an eye refraction have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 an office visit (99214), an eye examination with photos (92250), and an eye refraction (92015) provided on January 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture, total metabolic panel, immunoassay for analyte other than infectious agent antibody or infectious agent antigen, assay of protein serum, protein; electrophoretic fractionation and quantitation, assay of blood/uric acid, hematocrit, and hemoglobin provided on December 4, 2020.
You asked the Plan to pay for the routine venipuncture, total metabolic panel, immunoassay for analyte other than infectious agent antibody or infectious agent antigen, assay of protein serum, protein; electrophoretic fractionation and quantitation, assay of blood/uric acid, hematocrit, and hemoglobin. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the routine venipuncture, total metabolic panel, immunoassay for analyte other than infectious agent antibody or infectious agent antigen, assay of protein serum, protein; electrophoretic fractionation and quantitation, assay of blood/uric acid, hematocrit, and hemoglobin provided on December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $475 to $360 for the insertion of a breast implant following a mastectomy (19340) provided on January 15, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been 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 clearly says that you must pay a $475 copay for each visit to an outpatient hospital facility for Medicare-covered services.

You have been asked to pay a $475 copayment for the outpatient surgery provided. 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 adjust the copayment from $475 to $360 for the insertion of a breast implant following a mastectomy (19340) provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable gloves.

You asked the Plan to pre-approve disposable gloves. You say that you need gloves for when caring for the enrollee. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Nonreusable disposable supplies are not covered.

The requested disposable gloves are nonreusable. This means these items are not covered. Therefore, we decided that the Plan does not have to pre-approve disposable gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on February 10, 2021.

You asked the Plan to waive the coinsurance for DME. You say that you did not know you had a prescription for the device until you received it and do not need it. You state that you want to return the device. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 40% coinsurance for out-of-network DME and related supplies. 

You received DME from an out-of-network provider on February 10, 2021. Therefore, you are responsible to pay your share of the out-of-network services. The total allowed amount is $514.67 and 40% of that is $205.87.
You have been asked to pay the total coinsurance amount of $205.87 for DME. DME falls within the 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 DME provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for fine needle aspiration biopsy, including
ultrasound guidance; first lesion (CPT code 10005) provided on March 11, 2021, by the outpatient department
of an in-network hospital.

You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not have the
money for the high copayment. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file show that you received the fine needle aspiration biopsy on March 11, 2021, by the
outpatient department of an in-network hospital. You were asked to pay a $300 copayment for the outpatient
hospital facility visit. Your 2021 EOC states that enrollees must pay a $300 copayment for each in-network
Medicare-covered outpatient hospital facility visit. 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
fine needle aspiration biopsy, including ultrasound guidance; first lesion (CPT code 10005) provided on March
11, 2021, by the outpatient department of an in-network hospital.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).

You asked the Plan to pre-approve a CPAP device. You say that you need this to sleep. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires objective evidence of adherence to use of the PAP device. Adherence to therapy is defined as use of PAP at least 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 

We looked at the file and Medicare rules. The record shows that you have not used your PAP device for at least 4 hours on 70% of nights during a 30-day period. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from January 7, 2021, through January 11, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 $298 copayment per day, for days 1-7 for inpatient hospital care.

You have been asked to pay $894 ($298 copayment x 3 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from January 7, 2021, through January 11, 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 for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. 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 acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on January 26, 2021.

You asked the Plan to waive the copayment for an epidural injection. You say that you are shocked by the charges and were never told that you would owe such a high copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $335 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 

You received an epidural injection on January 26, 2021, at an outpatient hospital facility. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $335 copayment.

You have been asked to pay $335 copayment for an epidural injection. An epidural injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an epidural injection provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve endovascular revascularization for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary. 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 surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has lower extremity claudication. The enrollee has undergone an arterial duplex study that demonstrates bilateral, left worse than right peripheral vascular disease with hemodynamically significant stenosis and monophasic flow. The enrollee has a symptomatic obstructive lesion. The elements of the coverage rule are satisfied. 
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 surgery have been met. Therefore, we decided that the Plan has to pre-approve endovascular revascularization for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on August 31, 2020.
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that DME supplies must be provided with a proof of delivery. The required documentation pertaining to the proof of delivery of these supplies was not provided. 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 durable medical equipment provided to the enrollee on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 osteomyelitis and an infection of the foot. Medical conditions 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.
The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unskilled respite care, not hospice, per diem (S5151) to be performed by out-of-network facility.

You asked the Plan to pre-approve respite care. You say that the service is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit because the enrollee is not receiving hospice services and the care is custodial in nature.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of respite care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Additionally, respite care is reserved for members under hospice care. The record does not indicate that the member is receiving hospice services. Therefore, we decided that the Plan does not have to pre-approve unskilled respite care, not hospice, per diem (S5151) to be performed by out-of-network facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning rendered from September 29, 2020 to October 4, 2020.
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 procedure code 99497 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99497 (advance care planning) and 99291 (critical care services). Code 99497 is a column II code with a modifier indicator of 1 when billed with column I code 99291. Code 99497 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the advance care planning rendered from September 29, 2020 to October 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on February 23, 2021.
You asked the Plan to pay for oral hygiene instructions. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue 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 oral hygiene instructions (D1330) provided on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on August 4, 2020, to August 11, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you should only have to pay a $50 copayment. The Plan denied your request. The Plan says the correct coinsurance has been 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 Part B prescription drugs. 

You have been asked to pay a 20% coinsurance of the allowed amount for the injections that were provided. The total allowed amount is $1,314.08. The total amount you are being asked to pay is $262.82 ($1,314.08 x 20% = $262.82). The correct coinsurance has been applied to the injections that were provided. An injection falls within the Medicare Part B prescription drugs 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 an injection provided by a participating provider on August 4, 2020, to August 11, 2020.