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

We decided that the Plan does not have to pay for a shingles vaccine provided on October 24, 2019.
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because you were not aware that this vaccine was covered under Part D. The Plan denied your request. The Plan says the shingles vaccine is not covered under your medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine provided on October 24, 2019.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided
from January 23, 2020 to March 12, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you were told
that the services would be fully covered. 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 $30
copayment for outpatient rehabilitation services.
You received outpatient rehabilitation services from January 23, 2020 to March 12, 2020 for a total of 7 visits.
Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $30
(copayment) x 7 (PT visits) = $210.
You have been asked to pay the total copayment amount of $210 for outpatient rehabilitation services.
Outpatient rehabilitation services fall 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 outpatient rehabilitation services provided from January 23, 2020 to
March 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from February 8, 2019 to March 8, 2019.
You asked the Plan to reduce the copayments for the physical therapy visits. You say that you should only have one copayment because every visit was for the same issue. You say you were told you would only be charged a $30 copayment for the whole procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 copayment for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. You have been asked to pay a $30 copayment for each of the physical therapy visits. The physical therapy visits fall 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 reduce the copayments for the physical therapy visits provided from February 8, 2019 to March 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray consultation (76140) provided on November 6,
2019.
You asked the Plan to pay for the x-ray consultation. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says Medicare guidance says CPT code 76140 has a
status code of I.
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 find that CPT code 76140 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 76140 has a status code of I. This means that CPT code 76140 is not valid for Medicare purposes. Based
on this information, we decided that Medicare rules for coverage of the x-ray consultation have not been met.
Therefore, we decided that the Plan does not have to pay for an x-ray consultation (76140) provided on
November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 30,
2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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
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 a hospital outpatient clinic visit provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for peripheral nerve injections provided on
July 3, 2019 and July 31, 2019.
You asked the Plan to waive the copayments for peripheral nerve injections. You say that you were told that
the services would be fully covered and 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 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 $150
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received peripheral nerve injections provided at an outpatient hospital facility on July 3, 2019 and July 31,
2019. Peripheral nerve injections are considered outpatient surgical procedures. Therefore, you are responsible
to pay a $150 copayment per each injection. The total amount you owe is: $300.
You have been asked to pay the total copayment amount of $300 for peripheral nerve injections. Peripheral
nerve injections fall 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 copayments
for peripheral nerve injections provided on July 3, 2019 and July 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 13, 2020
to February 23, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from February 13, 2020 to February 23,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that the member was visiting family in Alaska and was sick. The Plan says that the member visited a walk-in clinic. The Plan denied your request. The Plan says prior authorization was not obtained.
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 physician services provided on January 1, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 22, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for PT/INR testing billed for dates of service December 16, 2019
through December 27, 2019.
You asked the Plan to pay for the PT/INR testing. You say that you would like reconsideration because this
service has been billed in accordance with Medicare guidelines. The Plan denied your request. The Plan says
this code has a frequency limitation of no more than one unit per 25 days which has been exceeded.
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 G0249 is provision of test materials and equipment for
home INR Monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous
thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home
and reporting of test results to physician; testing not occurring more frequently than once a week; testing
materials, billing units of service include 4 tests.
We find that CPT code G0249 is not supported in the record. Specifically, the record indicates that these
supplies were last paid on December 3, 2019. As this code encompasses four tests, billing for four tests weekly
exceeds what is covered by Medicare. Payment of this code weekly would indicate testing four times per week,
which is not covered by Medicare guidelines. Based on this information, we decided that Medicare rules for
coverage of the PT/INR testing have not been met. Therefore, we decided that the Plan does not have to pay for
PT/INR testing billed for dates of service December 16, 2019 through December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 4, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require prior authorization.
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
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 subsequent nursing facility care provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on December 2, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network provider, without prior authorization.
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. You are not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination services (71045, 73610 and 73630)
provided on October 23, 2019.
You asked the Plan to pay for the radiologic examination services. You say that you would like reconsideration
because the member was not enrolled in hospice on the date of service billed. The Plan denied your request.
The Plan says the provider would be responsible for payment of all Medicare covered services related or
unrelated to the member's terminal condition.
Medicare rules say that the provider, 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 radiologic examination services (71045, 73610 and 73630)
provided on October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 3, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 diagnostic radiology services provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for memory care facility services provided from January 1, 2020 to January 31, 2020.
You asked the Plan to pay for memory care facility services. You say that there are no memory care facilities in-network. The Plan denied your request. The Plan says this provider is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The services at issue were provided by a provider that is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of memory care facility services have not been met. Therefore, we decided that the Plan does not have to pay for memory care facility services provided from January 1, 2020 to January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have a condition indicated for coverage.
The Plan follows Medicare rules. Medicare rules say that Stereotactic Body Radiation Therapy is covered when other forms of radiotherapy, including but not limited to external beam and IMRT, cannot be safely or effectively utilized. 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 requested services. Our physician reviewer found that there are no data to suggest that SBRT would be superior to conventional radiotherapy. SBRT for bone metastases is not considered to meet medical necessity.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the services you require are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator provided on January 16, 2020.
You asked the Plan to pay for the home ventilator, any type, used with invasive interface (E0465). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. There is no physician order for a home ventilator in the file. The submitted order and medical necessity certificate is for portable oxygen and an oxygen concentrator. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the home ventilator provided on January 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET Scan (78815) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an OON PET Scan. You say that this is medically necessary. The Plan denied your request. The Plan says this service is available 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 provider at issue in this case is not a network provider with the Plan. 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 an OON PET Scan. Our reviewer says that the criteria for OON services have not been met. Our physician reviewer found the submitted documentation does not show that it is medically necessary for the enrollee to receive the requested scan out of network. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OON PET Scan have not been met. 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 an OON PET Scan. Therefore, we decided that the Plan does not have to pre-approve a PET Scan (78815) to be provided by an out of network (OON) provider.