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

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 13, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 13, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on February 4, 2020 by an OON provider.
You asked the Plan to pay for the initial nursing facility care. You say that the enrollee required weekly to bimonthly visits while at the nursing facility due to her conditions. The Plan denied your request. The Plan says the service was rendered by a non-participating provider, and prior authorization was not obtained. The Plan also says that the enrollee was referred by a non-participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care provided on February 4, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology monitoring (95999) provided on June 8, 2020.
You asked the Plan to pay for the neurological procedure (95999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure is considered a bundled procedure and cannot be paid separately.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the neurological procedure (95999) has a bundled relationship with the primary procedure. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiology monitoring (95999) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services rendered on June 15,
2020.
You asked the Plan to waive the copayment for these services. You say that you were in pain and have not
received a surgical shoe. The Plan denied your request. The Plan says the copayment was 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 $35
copayment for each visit for Medicare-covered podiatry services (medically necessary) received in a network
provider's office.
Review of the file shows that you received podiatry services on June 15, 2020. You have been asked to pay a
$35 copayment for these services. These services fall within the visit for Medicare-covered podiatry services
(medically necessary) received in a network provider's office 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 podiatry services rendered on June 15, 2020.
Your complaint about the provider 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe facedown recovery system provided on July 2, 2020You asked the Plan to pay forthe facedown recovery system. You say that this was medically necessary.The Plan denied your request. The Plan says that this is not covered by Medicare.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 forthe facedown recovery system provided on July 2, 2020
Appeal type: Imaging
Decision: Partially Favorable

You asked the Plan to pre-approveCT scans of the neck and chest. You say that you are appealing with supporting records.The Plan says that the denial of authorization for these tests is correct, because the next neck CT for follow-up should be done on June 16, 2021 and a chest CT is not indicated for follow-up.We decided that the Planhas to pre-approveneck CT.The Plan must follow Medicare rules. Medicare rules say that CT 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 neck CT. Our reviewer says that the enrollee meets the Medicare criteria for the requested neck CT scan. Our physician reviewer found that based on National Comprehensive Cancer Network (NCCN) guidelines and national protocols, a CT of the head and neck 6 months after the pervious CT scan would be in accordance with accepted standards.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neck CT have been met. Therefore, we decided that the Plan has to pre-approveneck CT. We also decided that the Plandoes not have to pre-approvechest CT.The Plan must follow Medicare rules. Medicare rules say that CT 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 chest CT. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested chest CT scan. Our physician reviewer found no rationale for this chest CT is offered other than for routine follow-up.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chest CT have not been met. Therefore, we decided that the Plan does not have to pre-approvechest CT.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 2, 2019.
You asked the Plan to pay for the lab services. You say that the ordering physician made a professional determination of urgent medical necessity. The Plan denied your request. The Plan says the incorrect date of service was billed on the claim.
The Plan must follow Medicare rules. Medicare rules say that the date of service of the test must be the date the specimen was collected.
We looked at the file and the rules. The documentation provided shows that the specimen for the testing at issue was collected on September 5, 2019. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 1, 2020 to June 10, 2020.
You asked the Plan to pay for home health services. 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. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was received with an inappropriate type of bill code. The claim was billed with type of bill 0324, which is not payable for per visit billing. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 1, 2020 to June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe transportation and set-up of the portable x-ray (Q0092, R0075) provided on February 23, 2020.. You say that you would like reconsideration because prior claims have always been paid with these specific codes.The Plan denied your request. The Plan says utilization of network providers is required when possible and available.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 forthe medical services provided on February 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 16, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services were not authorized to be performed by an out-of-network provider and the services were not urgent or emergent.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 involvingemergencies, 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 notpre-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 forthe medical services provided on January 16, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a leadless pacemaker (99223 and 33274) provided on July 13, 2020.
You asked the Plan to pay for the insertion of a leadless pacemaker. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says the documentation submitted does not indicate that the member was in an approved CED study.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of a leadless pacemaker have not been met. Specifically, the record does not include any indication that the member was enrolled in an approved CED study. Therefore, we decided that the Plan does not have to pay for the insertion of a leadless pacemaker (99223 and 33274) provided on July 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services received July 17, 2020 to July 31, 2020.You asked the Plan to pay forthe SNF services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received exceed the benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 14, 2020 to July 16, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services received July 17, 2020 to July 31, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (S9501) provided August 18, 2020 to August 22, 2020.
You asked the Plan to pay for the home health services. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim did not include a valid CPT code.
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 S9501 is not supported in the medical record. Specifically, this CPT code is marked with a status indicator of "I" and is not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (S9501) provided August 18, 2020 to August 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography scan (LDCT) for lung cancer screening (G0297).
You asked the Plan to pre-approve LDCT for lung cancer screening. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that for purposes of Medicare coverage of lung cancer screening with LDCT, beneficiaries must be 55 - 77 years of age. We looked at the file and Medicare rules. The record shows that the enrollee is 81. Based on this information, we decided that Medicare rules for coverage of LDCT for lung cancer screening have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography scan (LDCT) for lung cancer screening (G0297).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient services provided from April 14, 2019, to April 18, 2019.You asked the Plan to pay forthe inpatient services. You say that the services were medically necessary.The Plan denied your request. The Plan says the re-admission denial is for lack of clinical documentation.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 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 inpatient services.Our physician reviewer found the review indicates that the hospital did not provide sufficient information to allow a reasonable conclusion that the second admission was not preventable. There is no documentation on the preceding admission starting on April 6, 2019 available for review. Therefore, completeness of care, stability at discharge, and adequacy of discharge planning cannot be determined. After multiple attempts to obtain the first admission chart and information from the provider, none was sent to date.The re-admission denial is upheld for lack of clinical documentation. The review has determined that the readmission was medically necessary but given the documentation provided for review, it is not possible to determine if the readmission was the result of a premature discharge from the same hospital.We looked at this physician's review, the file, and Medicare rules. There areinsufficient medical records to show these were two separate admissions. Based on this information, we decided that Medicare rules for coverage of the inpatient services have been met.Therefore, we decided that the Plan doesnot have to pay forinpatient services provided from April 14, 2019, to April 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic electrical stimulation (G0283) and mechanical traction (97012) performed.

You asked the Plan to pay for chiropractic electrical stimulation and mechanical traction procedures. You say that this claim is and has previously been covered by Medicare.The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for chiropractic electrical stimulation (G0283) and mechanical traction (97012) performed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the frames for eyeglasses (V2020) purchased on September 8, 2020.
You asked the Plan to waive the cost share for the frames for eyeglasses. You say that you were under the impression your glasses would be fully covered. The Plan denied your request. The Plan says the allowance applied correctly, and your cost share is correct.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a $175 allowance for eyewear purchased every year. We looked at the file and the Plan's rules. The eyewear provider billed $315 and the Plan has applied the entire $175 allowance toward the charge. Therefore, you have been left with a cost share of $140. Based on this information, we decided that the Plan's rules for coverage of the frames have applied correctly. Therefore, we decided that the Plan does not have to waive the cost share for the frames for eyeglasses (V2020) purchased on September 8, 2020.
Your complaint about potentially receiving incorrect information from the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 23, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forthe medical services provided on July 23, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for x-rays on May 28, 2020.
You asked the Plan to waive the copayment for the x-rays. You say that you should not have to pay any more than a $35 copayment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received x-rays on May 28, 2020. You are asked to pay a $35 copayment for the x-rays. The health plan contract says that enrollees must pay a $35 copayment for basic radiology services by an in-network provider. 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 x-rays on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on April 12, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you are not back to normal after three surgeries.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 $35 copayment for each in-network specialist visit for Medicare-covered services.You have been asked to pay a $35 copayment for the office visit. The office visit 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 forthe office visit provided on April 12, 2019.