Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient hospital care.

You asked the Plan to pre-approve continued inpatient care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the enrollee's condition can be managed at home or an assisted living facility.

The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the enrollee's inpatient care.

In this case, the record does not show that the physician responsible for the enrollee's inpatient care concurs with this discharge. Therefore, we decided that the Plan has to pre-approve continued inpatient hospital 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice. The Plan says, per Medicare guidelines, the provider should bill Original Medicare for the services.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), the dental evaluation (D0150) and the unspecified dental procedure (D1999) provided on July 24, 2020.
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you exceeded the frequency limit of covered benefits for D1110 and D0150. Additionally, D1999 is not listed as a covered service.
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. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a dental cleaning (D1110) and a comprehensive exam (D0150) on July 24, 2020. The file also shows that you received these same dental services on February 3, 2020. The Plan's contract clearly says that dental code D1110 is covered once every 6 months. You received this service less than six months ago to which the Plan paid for. The Plan's contract clearly states that dental code D0150 is covered once every calendar year. You received this service less than one year ago from the July 24, 2020 date of service. Furthermore, dental code D1999 is not listed as a covered benefit under the Plan's supplemental dental benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), the dental evaluation (D0150) and the unspecified dental procedure (D1999) provided on July 24, 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 mental status change, sepsis and urinary tract infection. 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from March 20, 2021, forward.
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment as they were not a danger to themselves or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. The enrollee is unable to find an individualized treatment found however the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to themselves or others, auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any acute threat to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from March 20, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 physician's 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 physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because it was difficult to get a pre-authorization when it was an emergency situation. 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 a $120 copayment for emergency care.

You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency 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 emergency care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider.

You asked the Plan to waive the copayment for ambulance services. You say that you are not going to pay this copayment. The Plan denied your request. The Plan says the correct copayment 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 $75 copayment for ambulance services/in-network.

You have been asked to pay a $75 copayment for ambulance services. Ambulance services fall within the ambulance services/in-network 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 ambulance services provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit and nail debridement provided by an out-of-network provider.

You asked the Plan to pay for the home visit and nail debridement. You say that the services were medically necessary routine foot care. You say that the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 home visit and nail debridement provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid.

You asked the Plan to pay for the infectious agent detection. 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 infectious agent detection by nucleic acid.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services provided to the enrollee.

You asked the Plan to pay for medical nutrition therapy services. You say that this was medically necessary. The Plan denied your request. The Plan says this is only covered for diabetes and renal disease.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.

Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services provided to the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER), urgent care, and diagnostic radiology services.

You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $90 copayment for each Medicare-covered emergency room visit and a $50 copayment for each Medicare-covered urgent care provider visit.

Review of the file shows that you received ER services. You have been asked to pay a $90 copayment for these services. These services fall within the Medicare-covered emergency room visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received urgent care services. You have been asked to pay a $50 copayment for these services. These services fall within the Medicare-covered urgent care provider visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The total amount you have been asked to pay for these services is $140. 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 copayments for the emergency room (ER), urgent care, and diagnostic radiology services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285-26).

You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied your request. The Plan says this should not be billed with modifier 26.

The Plan must follow Medicare rules. Medicare rules say that modifiers 26 and TC cannot be used with codes that have a PC/TC Indicator of "0."

We looked at the file and Medicare rules. Code 99285 has a PC/TC indicator of "0" and cannot be billed with modifier 26. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285-26).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that a claim that is submitted for Cardiovascular Disease Screening shall contain 80061, 82465, 83718 or 84478.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment have not been met. Specifically, Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain, chest x-ray, and CT of the abdomen and pelvis.

You asked the Plan to pay for the CT of the head or brain, chest x-ray, and CT of the abdomen and pelvis. You say that you would like this claim to be reconsidered for payment. 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 CT of the head or brain, chest x-ray, and CT of the abdomen and pelvis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography.

You asked the Plan to pay for the echocardiography (93306). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the echocardiography was received in preparation for a procedure at the facility and is included in the facility PPS payment.

The Plan must follow Medicare rules. Medicare does not separately pay any provider other than the facility for services furnished to the enrollee for surgery. Based on this information, we decided that Medicare rules for coverage of the echocardiography (93306) have not been met. Therefore, we decided that the Plan does not have to pay separately for the echocardiography.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit and nuclear stress test with regadenoson injection.

You asked the Plan to waive the cost sharing for the office visit and nuclear stress test with regadenoson injection. You say that you were not aware that the cost for this test would be this high. You said that had you known the price, you would not have gone through with the appointment. The Plan denied your request. The Plan says you were charged these cost sharing amounts 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 $35 copayment for specialist office visits, 20% coinsurance for diagnostic radiology services, and 20% coinsurance for Medicare Part B drugs.

Records show that you had an office visit with your cardiologist. During this visit, you also received a nuclear stress test that included an injection of regadenoson. You have been asked to waive $35 copayment for the office visit, 20% coinsurance for the nuclear stress test and 20% coinsurance for the regadenoson injection. The office visit falls within the specialist office visits benefit category. The nuclear stress test falls within the diagnostic radiology benefit category. The regadenoson injection falls within the Medicare Part B drug 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 cost sharing for the office visit and nuclear stress test with regadenoson injection.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services with code S9328.

You asked the Plan to pay for the home infusion therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services with code S9328.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing.

You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.

The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in Illinois, while the member and laboratory are located in Texas. Therefore, we decided that the Plan does not have to pay for COVID-19 testing.