Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit, 30 minutes (90832) provided on December 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy visit, 30 minutes provided by an OON provider. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit, 30 minutes (90832) provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on September 24, 2019.
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 that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, you received services in the emergency department that included laboratory services. The Plan's contract clearly states covered outpatient hospital services include services in an emergency department or outpatient clinic, such as observation services or outpatient surgery. The Plan contract says there is a $0 copayment for laboratory and diagnostic tests billed by the hospital. The case file does not show that you were provided notification that the laboratory services you received would not be covered. Therefore, we decided that the Plan has to pay for the laboratory services provided on September 24, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from December 2, 2019 to December 30, 2019.You asked the Plan to pay forhome health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was billed incorrectly. The claim was billed with invalid codes.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from December 2, 2019 to December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for out-of-network vision services (99204, 92083, 99213, 92225, 92250, 92285, and 99212) provided from August 7, 2019 to December 30, 2019.You asked the Plan to waive the deductible for out-of-network vision services. You say that these services should be covered.The Plan denied your request. The Plan says these services processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible for out-of-network Medicare covered services. The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-network Medicare covered services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for out-of-network Medicare covered services. This cost sharing is a contractual obligation that had not been met at the time out-of-network vision services was received on August 7, 2019 to December 30, 2019.Therefore, we decided that the Plan does not have to waive the deductible for out-of-network vision services (99204, 92083, 99213, 92225, 92250, 92285, and 99212) provided from August 7, 2019 to December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered on December 10, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered. The Plan must follow Medicare rules. The rules say that the panel must be billed with procedure code 81479. The file shows that the panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing rendered on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) polycarbonate lens (V2784) tint, photochromatic lens (V2744) progressive lens (V2781) purchased on October 15, 2019.
You asked the Plan to pay for the vision services. You say that you have been going to this provider for years and you can get eyeglasses on the same day while the network provider takes 15 days to provide eyeglasses. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider.
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. The Plan covers these services when services must be received from a network provider. We looked at the file and the Plan's rules. Services must be provided by a network provider to be covered. You can find this information on page 33 of the plan's 2019 Evidence of Coverage. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) polycarbonate lens (V2784) tint, photochromatic lens (V2744) progressive lens (V2781) purchased on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on December 13, 2019 from an out-of-network provider.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 there was no prior authorization for services. The Plan states you say the Plan provider wrote orders. The Plan states written orders were not provided with the appeal and review of medical records only show the Plan provider wrote an order for admission to the skilled nursing facility.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 has network providers available who can provide 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 services provided to the enrollee on December 13, 2019 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (92015) provided July 18, 2019.
You asked the Plan to pay for the vision services. You say that you showed them your insurance and was not told that they no longer took the insurance. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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. The Plan covers these services when refraction services is not covered. We looked at the file and the Plan's rules. Refraction is not listed and therefore not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for refraction services (92015) provided July 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 74021 provided on December 24, 2019.
You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are included in payment for another service.
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, we have confirmed that code 74021 for the x-ray has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray coded 74021 provided on December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2019.
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 from November 1, 2019 through November 19, 2019.You asked the Plan to waive the copayment for the SNF services. You say that you cannot afford this payment.The Plan denied your request. The Plan says that this claim 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 $172 copayment for each day for Medicare-covered SNF services, for days 21-100. You have been asked to pay a $3,096 copayment for the SNF services. The SNF services falls within the Medicare-covered SNF services, for days 21-100 benefit category. The file indicates you were in a SNF for twenty-eight (28) days. 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 from November 1, 2019 through November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 3, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 21, 2019 through October 24, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there was no indication that short-term observation combined with outpatient follow-up and use of oral antibiotics would not be sufficient for this case which appears not be complicated, based on the documentation provided. Therefore, there was no clear evidence provided suggesting a need for at least a two-midnight stay in the acute care hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 21, 2019 through October 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 3, 2020 through January 5, 2020.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found as the testing and emergency department (ED) evaluation overall suggested resolution of the problem and no evidence of an active acute illness to warrant admission status, it appeared that there was no reasonable expectation for the patient to require at least a two-midnight inpatient stay. Management and preventative measures could be implemented as outpatient.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 3, 2020 through January 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on October 22, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with the charges.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 toits 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on October 22, 2019. The allowed amount is $1.97 and 20% of that is $.39. You have been asked to pay the total coinsurance amount of $.39 for a Medicare Part B drug. A Medicare Part B drug 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 fora Medicare Part B drug provided on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have a medical need for the requested orthotics. You say that the requested orthotics are desperately needed for your mobility. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a knee orthosis (L1830) provided to the enrollee on .
You asked the Plan to preapprove the knee brace. You say that you should be able to have a second knee brace. The Plan denied your request. The Plan says this item is a duplicate and therefore is not covered.
The Plan must follow Medicare rules. Medicare rules say when a claim that is received for a service that has been previously processed, and a Medicare allowed amount has been established, the second claim will be denied as a duplicate. Therefore, we decided that the Plan does not have to preapprove a knee orthosis (L1830) provided to the enrollee on .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64490).
You asked the Plan to pre-approve the injections. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of facet joint injections.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the injections. Our reviewer says that facet joint injections are not medically necessary. Our physician reviewer found that you have chronic neck pain as well as low back pain. Your request is for a C1-C2 facet block. However, there is little literature to determine the outcome and safety of the procedure. Therefore, your request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64490).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. (CPT Code 99223) provided to the enrollee on November 14, 2019.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says payment is not allowed for this service because the CPT code billed is not appropriate of the place of service submitted. The Plan states the provider may submit a corrected claim for reconsideration however this claim processed correctly as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. CPT code 99223 is not approved by Medicare to be done in a high level place of treatment (i.e. ambulatory surgical center, home health nurse visit, chiropractor's office). Any services that Medicare does not allow to be done in that setting are allowed at $0.00. Therefore, we decided that the Plan does not have to pay for making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. (CPT Code 99223) provided to the enrollee on November 14, 2019.