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

We decided that the Plan does not have to pay for the laboratory work provided on July 14, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you submitted your bill for review. The Plan
denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 14, 2020 by
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided December 10, 2020 to December 20, 2020.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $178 per day copayment for Skilled Nursing Facility services. You have been asked to pay a $178 per day copayment for 11 days of skilled nursing facility services, for a total of $1,958. The plan did not assess a copayment for days 1-17 of skilled nursing services, or for the discharge day. 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 skilled nursing facility services provided December 10, 2020 to December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99214) provided on October 27, 2020
by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are attaching medical notes to show medical
necessity. You were under the impression that you were a participating provider. Please review notes and
reconsider the claim for payment. 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. Nonemergent
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for outpatient office visit (99214) provided on
October 27, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of upper and lower extremities provided on November 5, 2020.
You asked the Plan to waive the copayment for the ultrasound of upper and lower extremities. You say that you are appealing this 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at an in-network freestanding facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $100 copayment for the ultrasound of upper and lower extremities.
You have been asked to pay a $78.99 copayment for the ultrasound of upper and lower extremities. The ultrasound of upper and lower extremities falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 ultrasound of upper and lower extremities provided on November 5, 2020.Your complaint about your dissatisfaction with the Plan's increasing benefit costs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.
You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 an intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for low back pain. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete replacement of the shoulder joint (CPT code 23472), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for complete replacement of the shoulder joint (CPT Code 23472) is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve complete replacement of the shoulder joint (CPT code 23472), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided September 28, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the coverage criteria for the continuous glucose monitor have not been satisfied.
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. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided August 12, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405 and 81406 are not supported in the medical record. Specifically, per Medicare rules this service should be reported with CPT code 81479 and not unbundled to separate codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on July 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services were provided to the enrollee at the long term care facility where she resides and was medically necessary. 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 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 domiciliary or rest home visit (99335) provided on July 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (AED)
rendered from November 3, 2020 to December 3, 2020.
You asked the Plan to waive the coinsurance for these services. You say that the provider quoted you at a price
of $50 per month. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for per Medicare-covered durable medical equipment item and related supplies.
Review of the file shows that you received an AED from November 3, 2020 to December 3, 2020. You have
been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered
durable medical equipment item and related supplies 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. The Plan cannot be held responsible for possible misinformation
regarding your cost sharing given by a provider. Therefore, we decided that the Plan does not have to waive the
coinsurance for the automatic external defibrillator (AED) rendered from November 3, 2020 to December 3,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on December 16, 2020.
You asked the Plan to pay for the eyeglasses. You say that you rely on the nursing home to obtain the authorization. The Plan denied your request. The Plan says the eyewear is covered when provided by the Plan's vision provider.
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 when you use the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's vision provider and there is no authorization for the eyeglasses. 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 provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on November 6, 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. Medicare rules say that claims must be billed with the appropriate POS code. We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed with POS code 12 for home. This is the incorrect place of service code. Therefore, we decided that the Plan does not have to pay for the office visit rendered on November 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on August 31,
2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on
August 31, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6531 that were issued on December 3, 2020.
You asked the Plan to pay for the compression stockings. You say that you were unaware of the plan limitations. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6531 that were issued on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these out-of-network services were not approved in accordance to Plan regulation.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 26, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (71046, Q0092, R0070) provided on September 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that the diagnostic radiology procedures that you are billing does not require authorization. The plan should re-process this claim for payment. You have included with this appeal the medical records for review. 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 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 portable x-ray services (71046, Q0092, R0070) provided on September 3, 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 services provided to the enrollee by an out-of-network
provider on November 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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
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 for the services provided to the enrollee by an out-of-network
provider on November 10, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services (A0425 and A0429) provided on October 3, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the member had multiple trips on the same date. The Plan denied your request. The Plan says that this claim was billed with an invalid modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code A0425 and A0429 is supported in the record. Specifically, the record clearly indicates that the member received multiple trips on the same date of service. This appears to be the correct use of modifier 59 as this service was distinct and separate. Additionally, no regulations were provided by the Plan to show that modifier 59 cannot be billed with the billed services. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services (A0425 and A0429) provided on October 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 21, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says payment for this service is included in the inpatient rate.
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation furnished to inpatients is covered under Part A. We looked at the file and Medicare rules. The ambulance services were provided while the enrollee was under inpatient status. Payment for the ambulance services is included in the payment for the inpatient stay. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 21, 2020.