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

We decided that the Plan does not have to pay for critical care services (99291) provided on June 26, 2020.

You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the record. Specifically, the record submitted does not include a critical care note or documentation of the amount of time spent rendering the billed service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82607, 80061, 36415, and 80053 provided on November 11, 2020, by a non-participating provider.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider is not a network provider with the Plan. The Plan states the services were not referred by a network provider or rendered in a participating facility. The Plan states they also have also determined that these services are not urgent or emergent, nor were they approved in advance.

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 (CPT code(s): 82607, 80061, 36415, and 80053 provided on November 11, 2020, by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network dermatology services provided on January 22, 2021 and January 25, 2021.

You asked the Plan to pay for these services. You say that you were out of the area and had to go to urgent care. At urgent care they told you that you should see a dermatologist for follow up. The Plan denied your request. The Plan says you did not have prior authorization for out of network care. The Plan states that you did not work with the Plan to get prior authorization for dermatology services out of 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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. Once the emergency was over and your sought follow-up, you needed to work with the Plan to get prior approval. 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 out of network dermatology services provided on January 22, 2021 and January 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone and/or joint imaging of the whole body (78306).

You asked the Plan to pre-approve a whole-body bone and/or joint imaging. You say that the requested service is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a whole-body bone and/or joint imaging. Our reviewer says that the requested service is not reasonable or medically necessary. Our physician reviewer found that PET scans are not indicated in metastatic renal cell cancer. This is due in part to limited FDG activity in many renal tumors as well as the physiological excretion of FDG into the urine. A computed tomography (CT) scan would be indicated prior for work-up of left lower quadrant pain. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a whole-body bone and/or joint imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone and/or joint imaging of the whole body (78306).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided November 3, 2020, and crown - porcelain/ceramic (D2740).

You asked the Plan to pay for the oral evaluation and crown. You say that out-of-network services are covered in full. The Plan denied your request. The Plan says you received services from a Medicare Opt-Out provider and therefore they are not covered.

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. The Plan covers the oral evaluation and crown when the services are rendered by a licensed dental provider who accepted Medicare patients in the United States and has not opted out of Original Medicare. 

We looked at the file and Medicare rules. You received services from a provider who has opted out of original Medicare. Based on this information, we decided that the Plan's rules for coverage of the oral evaluation and crown have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the crown (porcelain/ceramic (D2740) provided November 3, 2020, to December 9, 2020.

Your complaint about the potentially poor service and confusing information received from your insurance company is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that as you receive the specimen from the ordering provider you are not involved in the process of obtaining authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan, the ordering provider is also out-of-network with the Plan, and 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 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 laboratory testing provided on January 11, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cataract removal provided on July 28,
2020.

You asked the Plan to waive the coinsurance for cataract removal. You say that you disagree with the charges
because you have never been charged in the past. 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 20%
coinsurance for outpatient hospital services.

You received cataract removal on July 28, 2020. The total allowed amount is $1,151.72 and 20% of that is
$230.34.

You have been asked to pay the total coinsurance amount of $230.34 for cataract removal. Cataract removal
falls within the outpatient hospital 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 coinsurance
for cataract removal provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 3, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 services 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 these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on November 24, 2020.

You asked the Plan to pay for therapeutic CGM. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this item is correct, because with the information submitted the Plan cannot determine if a physician's order was given, how the enrollee came to this provider, or whether this item was necessary.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Medicare rules state that the supplier must furnish to the Plan sufficient information to determine whether payment is due for a billed claim. 

We looked at the file and Medicare rules. No supporting medical records were submitted to show that the enrollee met the Medicare criteria for coverage of a therapeutic continuous glucose monitor. The Plan requested supporting records but none were submitted. Without this information, you have not furnished sufficient information to the Plan to justify payment of this claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair railing (E1399) provided on February 13, 2020.

You asked the Plan to pay for a stair railing. You say that the requested item was needed for the enrollee's
safety and care. The Plan denied your request. The Plan says rules for payment have not been met because the
requested item does not primarily serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for a stair railing (E1399) provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT 99307) provided to the enrollee on October 12, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the subsequent nursing facility care is billed with an inappropriate place of service being inpatient.

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 99307 is "Subsequent nursing facility visit, typically 10 minutes per day." 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the provider billed place of service 21 (inpatient hospital), however, this code falls under nursing facility care ((long term care or SNF facility), therefore place of service 21 would be inappropriate. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (CPT 99307) provided to the enrollee on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $45 copayment charged for specialist services provided on October 26, 2020.

You asked the Plan to waive this copayment. You say that you do not believe you should have to pay this copayment. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.

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 $45 copayment for specialist services. 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 $45 copayment charged for specialist services provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical or thoracic facet injections.

You asked the Plan to pre-approve cervical or thoracic facet injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific criteria are met. 

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 cervical or thoracic facet injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the request is considered not medically reasonable or necessary as it does not meet the coverage criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical or thoracic facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical or thoracic facet injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide additional aquatic therapy sessions.

You asked the Plan to provide additional aquatic therapy sessions. You say that the enrollee needs additional aquatic therapy sessions for weight loss and pain management. The Plan denied your request. The Plan says aquatic therapy is no longer so complex that it requires a therapist.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 provide additional aquatic therapy sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The patient has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional aquatic therapy sessions have not been met. Therefore, we decided that the Plan does not have to provide additional aquatic therapy sessions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses purchased from an out-of-network provider on October 12, 2020.

You asked the Plan to pay for the eyeglasses. You say that you purchased these glasses online due to COVID-19 concerns and feel the Plan should make an exception for out-of-network coverage. The Plan denied your request. The Plan says they do not cover out-of-network services.

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 up to $200 for eyewear when it is received from a Plan-participating provider. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses purchased from an out-of-network provider on October 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, abdomen and pelvis; without contrast material (CPT code 74176) provided to the enrollee on August 17, 2020.

You asked the Plan to pre-approve the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the claim has processed correctly.

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 CT scan have not been met. The service denied because based on enrollee's claims history, the claim was billed with an inappropriate place of service. According to claims history, the enrollee was inpatient from August 11, 2020, through August 27,2020. Therefore, we decided that the Plan does not have to pre-approve CT, abdomen and pelvis; without contrast material (CPT code 74176) provided to the enrollee on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 8, 2020.

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the medical records establish the medical necessity of the requested items. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual except in certain defined circumstances as set forth in the "Medicare rules" section of this letter. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and a suspension sleeve have not been met. Specifically, the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no payment may be made for these items. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72100) and the x-ray exam of the hip (73501) provided on November 12, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment of these 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. 

You were 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 x-ray exam of the lumbar spine (72100) and the x-ray exam of the hip (73501) provided on November 12, 2020.