Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the set up and transport of x-ray equipment with CPT codes Q0092 and R0070 provided.

You asked the Plan to pay for CPT codes Q0092 and R0070. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure codes Q0092 and R0070 were provided in a facility with a place of service code of 31. Procedure codes Q0092 and R0070 have a PC/TC Modifier Status of 3, which specifies a Technical Component only code.Therefore, we decided that the Plan does not have to pay  for the set up and transport of x-ray equipment with CPT codes Q0092 and R0070 provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF services. You say that SNF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF services. have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4) and comprehensive oral evaluation (D0150) provided on July 22, 2020.
You asked the Plan to pay for the 2D oral/facial photographic image and comprehensive oral evaluation. You say that you spoke with the Plan prior to receiving these services, and were not informed of any frequency limitations or that necessary x-rays were a non-covered service. You also say that the provider's office advised that your insurance would cover the cost of these services. The Plan denied your request. The Plan says 2D oral/facial photographic image is not a covered benefit under your dental plan. The Plan also says that the comprehensive oral evaluation exceeds the frequency limitation in your benefit plan.
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, 2D oral/facial photographic image (D0350) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on December 5, 2019, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the four 2D oral/facial photographic images (D0350 x4) and comprehensive oral evaluation (D0150) provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 29, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that authorization should not be needed under telemedicine. The Plan denied your request. The Plan says the member's network primary care physician (PCP) did not refer for services. The Plan states they require utilization of network providers when possible and available, and requires authorization for certain services The Plan states there is no necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on June 29, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on November 29, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on July 20, 2020.You asked the Plan to waive the copayment forthe colonoscopy. You say that this was a routine colonoscopy. You say that this is an unreasonable amount to pay for removing one polyp.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to itsenrollees 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 in-network, Medicare-covered ambulatory surgical center visit.You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed which 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment forthe colonoscopy provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe frames for eyewear (V2020) provided on September 10, 2020.You asked the Plan to waive the cost share forthe frames for eyewear. You say that you would like this claim fully covered.The Plan denied your request. The Plan says they have provided the $100 allowance towards the frame and the remaining amount is the cost share you owe.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 provides a $100 allowance toward the cost of routine eyewear every two years.We looked at the file and the Plan's rules. The provider has charged $204 for the eyewear and the Plan has applied the $100 allowance. Therefore, the cost share charged of $104 is correct in this situation. Based on this information, we decided that the Plan's rules for coverage of the frames for eyewear have applied correctly.Therefore, we decided that the Plan does not have to waive the cost share forthe frames for eyewear (V2020) provided on September 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the echocardiogram, the Part B medication, and the SPECT test provided on April 13, 2020.
You asked the Plan to waive the coinsurance for the echocardiogram, the Part B medication, and the SPECT test. You say that your Explanation of Benefits shows a remark that says you do not have to pay this amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare-covered diagnostic procedures and tests, 20% of the cost per prescription or refill for certain drugs and biologicals that you can't give yourself, and 20% of the cost for each Medicare-covered diagnostic radiology and complex imaging service. You have been asked to pay a total of $429.67 for the echocardiogram, the Part B medication, and the SPECT test. The echocardiogram, the Part B medication, and the SPECT test fall within the "Outpatient hospital services" benefit category. The Explanation of Benefits shows that your cost share was applied from the approved amount. See chart below.

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 echocardiogram, the Part B medication, and the SPECT test provided on April 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formammography services (77065, G0279) provided May 22, 2020.You asked the Plan to pay forthe mammography services. You say that the service was medically necessary.The Plan denied your request. The Plan says the units billed exceeds the allowable amount.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT codes 77065 & G0279 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the mammography services have not been met.Therefore, we decided that the Plan does not have to pay formammography services (77065, G0279) provided May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine venipuncture (36415), blood count; complete (cbc), automated (85025), comprehensive metabolic panel (80053), lipid pane (80061) and hemoglobin; glycosylated (83036) provided on May 15, 2020 by an out of network (oon) provider.You asked the Plan to pay forroutine venipuncture, blood count, comprehensive metabolic panel, lipid pane and hemoglobin; glycosylated. You say that the services were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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 forthe routine venipuncture (36415), blood count; complete (cbc), automated (85025), comprehensive metabolic panel (80053), lipid pane (80061) and hemoglobin; glycosylated (83036) provided on May 15, 2020 by an out of network (oon) provider
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient hospital care provided from July 1, 2019, to July 4, 2019, by an out-of-network (OON) provider.You asked the Plan to pay forthe inpatient hospital care. You say that the services provided were medically necessary for the enrollee.The Plan denied your request. The Plan says that the care provided was unauthorized post-stabilization care.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 hospital care. Our reviewer says that the inpatient care was medically necessary. Our physician reviewer found the patient was not stable for transfer without knowing the cause of the enrollee's emergency medical condition.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 inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe inpatient hospital care provided from July 1, 2019, to July 4, 2019, by an out-of-network (OON) provider.

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 copayment for the specialist office visit provided on
August 13, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to
pay the $45 copayment because you the doctor did not do anything. You say the doctor cancelled your surgery
knowing you went there to talk about your surgery. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for each in-network Medicare-covered visit with a specialist.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
you were seen for a specialist office visit.
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 specialist office visit provided on August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial observation care (99220) provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forinitial observation care. You say that medically necessary services were rendered in good faith.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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 forthe initial observation care (99220) provided on August 26, 2020 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided from February 26, 2020 to July 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 rest home visit services provided from February 26, 2020 to July 14, 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 forpodiatry services provided on August 13, 2020.You asked the Plan to waive the copayment forpodiatry services. You say that you received routine foot care for your diabetes and should not owe a copayment.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, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for podiatry services. The medical records show that you received podiatry services on August 13, 2020, to treat a condition of the foot. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for podiatry services. Podiatry services fall within the podiatry services benefit category. This means thatyou 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 forpodiatry services provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Oncology consultation (99204) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe consultation. You say that you feel that this provider would be the most appropriate to provide treatment. You do not want to go to the networkprovider due tothemhaving very poor ratings online.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe Oncology consultation (99204) to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the SNF care provided from May 19, 2020, to June 17, 2020.
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the enrollee did meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee also required daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for the SNF care provided from May 19, 2020, to June 17, 2020.
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.