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

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT code 99308) provided from January 8, 2020, through January 22, 2020, by a non-participating provider.

You asked the Plan to pay for the medical services. You say that the provider rendered services at an in-network participating facility. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-participating provider with the enrollee's health plan. The Plan states the enrollee's network primary care physician (PCP) did not refer for services.

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 subsequent nursing facility care (CPT code 99308) provided from January 8, 2020, through January 22, 2020, by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology exam of tissue provided on December 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the pathology exam of tissue. You say that you were unaware you would need a referral since the service was to rule-out cancer. 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 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 pathology exam of tissue provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, monaural, BTE (V5257) received
November 18, 2020, received from a non-participating provider.

You asked the Plan to pay for the hearing aid. You say that you need the hearing aids, and you cannot hear
without them. The Plan denied your request. The Plan says hearing aids purchased from non-participating
hearing providers will not be covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from a plan-participating hearing vendor.

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 hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the
hearing aid, digital, monaural, BTE (V5257) received November 18, 2020, received from a non-participating
provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on January 21, 2021.

You asked the Plan to waive the copayment for the endoscopy. You say that you were advised when you signed up for this policy that screening colonoscopies were covered. You say that your colonoscopies in the past were covered in full. 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 $350 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.

You have been asked to pay $246.42, which is less than the standard $350 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical service. 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 endoscopy provided on January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucynta tab 100mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta tab 100mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of a broken crown provided on November 10, 2020 by an OON provider.
You asked the Plan to pay for the crown replacement. You say that you believe these services should be covered. The Plan denied your request. The Plan says the service is not a covered benefit.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the replacement of a broken crown provided on November 10, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on
July 14, 2020.

You asked the Plan to pay for the office visit. You say that you were unaware that you were out-of-network and
were under the impression you would receive compensation. You say that the authorization policy should be
waived, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says prior
authorization for out-of-network services 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 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 office visit provided by an out-of-network
provider on July 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 4, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $90 copayment for each emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You were admitted for hip arthroplasty revision due to infection and subsequently had a perforated ulcer that required operative repair. You continue to receive acute care services and these have not been denied. The medical records provided do not indicate that you require services which you are currently not receiving but that would be available at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided on December 11, 2020.
You asked the Plan to waive the copay for the services provided. You say that you did not benefit from this service The Plan denied your request. The Plan says the copay applied based on your contract.
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 copay for ground ambulance services per one-way trip. You have been asked to pay a $40 copay for the services provided. The services fall within the ambulance 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 copay for the ambulance transportation services provided on December 11, 2020.
Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for an INR demonstration (G0248) and has to reduce the cost-sharing charges for home INR testing materials (G0249).
You asked the Plan to waive the copayments for an INR demonstration (G0248) and home INR testing materials (G0249). You say that you were pre-approved for the services. The Plan says that the claims were processed correctly and you are being charged the correct amount.
We decided that the Plan has to waive the copayment for an INR demonstration (G0248) provided on May 6, 2020.
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 does not say in clear and accurate terms how much you should expect to pay for a home demonstration of INR testing provided by a laboratory. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $45 copayment for a home demonstration of INR testing provided by a laboratory. The Plan contract does not clearly say how much enrollees must pay for a home demonstration of INR testing provided by a laboratory. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayments for an INR demonstration (G0248).
We also decided that the Plan has to reduce the cost-sharing charges for home INR testing materials (G0249) from $450 to $184.60.
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 medical supplies. The record shows that you received home INR testing materials (G0249) from May 6, 2020, to February 8, 2021, for a total of 10 services. The total allowed amount per each service is $92.30 and 20% of that is $18.46. The total amount you owe is: $18.46 (coinsurance) x 10 (services) = $184.60. Therefore, we decided that the Plan has to reduce the cost-sharing charges for home INR testing materials (G0249) from $450 to $184.60.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visits, and the ophthalmic biometry provided from December 31, 2020, to January 22, 2021.
You asked the Plan to waive the deductible for the specialist office visits and the ophthalmic biometry. You say that you do not understand how these charges were applied to the deductible. You say other doctor charges have been paid previously. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $198 deductible and a $203 deductible that applies towards specialist office visits and ophthalmic biometry. The specialist office visits and ophthalmic biometry you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible and a $203 deductible that applies towards specialist office visits and the ophthalmic biometry.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visits and the ophthalmic biometry was received on December 31, 2020 to January 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visits, and the ophthalmic biometry provided from December 31, 2020, to January 22, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that your needs could be managed at a lower level of care.

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 surgical repair of an ankle fracture after a fall. Your medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period 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. Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) and complete mandibular denture (D5120) and are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on June 14, 2019 and your complete maxillary denture (D5110) and complete mandibular denture
(D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter insertion rendered on June 28, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that additional surgical procedures performed by the
surgeon on the same day are reported with modifier "-51."
We looked at the file and Medicare rules. The file shows that procedure code 36556 (insertion of non-tunneled
centrally inserted catheter) was billed with modifier -51; however, the records show that the services were not
an additional surgical procedure. 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 catheter
insertion rendered on June 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion surgery.
You asked the Plan to pre-approve lumbar fusion surgery. You say that the requested surgery is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested surgery is not medically reasonable and 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 lumbar fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for lumbar fusion surgery have not met. There is no radiographic instability. There is not a recent magnetic resonance imaging scan within the past 6 months. Therefore, in this case lumbar fusion surgery is not medically 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 lumbar fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion surgery.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on September 2, 2020.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in the payment to the facility and not separately reimbursable to this provider in this place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99153 is not supported in the record. Specifically, CPT code 99153 is a technical component only code and does not include any physician work. CPT code 99153 is not a considered a professional component of the service. Payment for CPT code 99153 is included in the payment to the facility and not separately reimbursable to the physician. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on September 2, 2020.