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

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on August
3, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services were billed incorrectly.

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 codes G0483 and 80307 are not supported in the medical record. Specifically, the place of
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was
obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for
the drug testing coded G0483 and 80307 provided on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from September 1, 2020, to September 15, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed that you would owe anything from the stay and 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 $0 copayment for days 1-20 and a $178 copayment for days 21-100 for SNF care. You had a SNF stay from September 1, 2020, to September 15, 2020. The record shows that you had a previous SNF stay for a total of 15 days. Therefore, you are not being charged a copayment for days 16-20 (September 1, 2020, to September 5, 2020). You are responsible to pay a $178 copayment for days 21-29 (September 6, 2020, to September 14, 2020). $178 (copayment) x 9 (SNF days) = $1,602. You have been asked to pay the total copayment amount of $1,602 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from September 1, 2020, to September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on
December 15, 2020.
You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says the claim processed correctly based on your Plan's design.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $25 copayment for Physician/Practitioner services, including doctor's office visits. You have been asked to pay $25 copayment for the physician's services. The physician's services falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physician's services provided on December 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient stay provided from November 18, 2020, through November 19, 2020.
You asked the Plan to waive the coinsurance for the inpatient stay. You say that you had surgery and were informed you had to spend the night in the hospital. You say that you would like to appeal the costs to see if the Plan can make adjustments. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each in-network, Medicare-covered hospital stay. You have been asked to pay $1,878.36, which is less than the standard 20% coinsurance for the inpatient stay. The inpatient stay falls within the "Inpatient Hospital 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 coinsurance for the inpatient stay provided from November 18, 2020, through November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on November 3, 2020.
You asked the Plan to pay for the hearing aids. You say that these hearing aids are necessary and should be covered. You say that the provider you used was not in the Plan's network, but you live in a rural area and this provider has cheaper prices than alternative options. The Plan denied your request. The Plan says hearing aids are not covered by Medicare or by the Plan under any circumstances. You did not contact the Plan to verify your benefits prior to services.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the needle biopsy provided on January 7, 2021.
You asked the Plan to waive the copayment for the needle biopsy. You say that you were an inpatient at the hospital on this date and should not have a copayment. The Plan denied your request. The Plan says the copayment 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 $45 copayment for each in-network specialist visit for Medicare-covered services. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You have been asked to pay a $45 copayment for the needle biopsy. The needle biopsy falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the biopsy was performed prior to being admitted as an inpatient. 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 needle biopsy provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on January 11, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 drug testing provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on August 10, 2020, to September 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 outpatient hospital services provided on August 10, 2020, to September 9, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain.

The Plan must follow 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollee's chronic persistent pain. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is the best outcome to recover in the shortest amount of time. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for abdominal surgery to correct a hernia and remove a kidney. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye drainage procedure (65800) provided on February 21, 2020.
You asked the Plan to pay for an eye drainage procedure. You say that records for this service have been provided. The Plan denied your request. The Plan says the provided records are illegible.
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 65800 is paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous.
We find that CPT code 65800 is not supported in the medical record. Specifically, the submitted medical records are illegible. The file shows that the Plan made attempts to obtain clearer records without success. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of an eye drainage procedure have not been met. Therefore, we decided that the Plan does not have to pay for an eye drainage procedure (65800) provided on February 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on
September 15, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. You say that this claim should be
approved because the service was not related to the enrollee's hospice diagnosis. The Plan denied your request.
The Plan says the Medicare Hospice benefit, through fee-for-service Medicare, covers all Hospice care from
the effective date of election to the date of discharge or revocation. The Plan also says that during the election,
fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness
starting on the date of the Hospice election until the first day of the month following the month in which
Hospice is revoked or discharged.
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 ambulance service and ground mileage provided on
September 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve routine transportation trips. You say that you need transportation to a routine dialysis appointment. The Plan denied your request. The Plan says that the benefit is limited to unlimited rides up to 30 days upon referral from a Plan Clinical Advocate, immediately following inpatient hospital discharges or skilled nursing facility stays.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 30 days upon referral from a Plan Clinical Advocate, immediately following inpatient hospital discharges or skilled nursing facility stays. We looked at your request, the records in the case file, and the rules. The file does not indicate you are requesting transportation within 30 days of being in the hospital or skilled nursing facility. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the office visit provided on December 8, 2020.

You asked the Plan to waive the co-payment for the office visit. You say that this was a 90 day follow up. You say that you were told there was no charge for a follow up. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co-payment for each specialist visit.

You have been asked to pay a $35 co-payment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a co-payment would be waived for a service performed as a follow-up. 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 co-payment for the office visit provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and an EKG provided by a participating provider on November 2, 2020.
You asked the Plan to waive the copayment for an office visit and an EKG. You say that you met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct copayments have 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 $40 copayment and a $30 copayment for physician/practitioner services/specialist and outpatient diagnostic tests/non-radiological diagnostic services/in-network. You have been asked to pay a $40 copayment for an office visit. You have been asked to pay $15.96 which is less than your copayment amount of $30 for an EKG. The total amount you are being asked to pay is $55.96 ($40 + $15.96 = $55.96). An office visit falls within the physician/practitioner services/specialist benefit category. An EKG falls within the outpatient diagnostic tests/non-radiological diagnostic 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 an office visit and an EKG provided by a participating provider on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2020, by a nonnetwork
provider.

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 services were rendered by a non-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.

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 laboratory services provided on July 14, 2020,
by a non-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on February 25, 2021.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says refractive services must be performed by the Plan's vision care provider to be covered.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained through the Plan's vision care provider. We looked at the file and the Plan's rules. The file shows that the eye refraction was not provided by the Plan's vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on February 25, 2021.