Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy evaluation and visit provided on September 30, 2019.You asked the Plan to waive the copayments forthe physical therapy evaluation and visit. You say that you are being charged for an evaluation which was not provided. You say you were given the TENS unit and a bag of ice. The Plandenied 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 $40 copayment per visit per therapy type.You have been asked to pay a $40 copayment for the physical therapy evaluation and a $40 copayment for the visit. The physical therapy evaluation and visit fall within the "Outpatient rehabilitation services" benefit category. The medical record shows you did receive an initial physical therapy evaluation and neuromuscular reeducation, therapeutic activities, and electrical stimulator.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 copayments forthe physical therapy evaluation and visit provided by on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (72100, R0070, Q0092) provided on October 23, 2019.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were in-network providers that could render the services at issue.
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 portable x-ray services (72100, R0070, Q0092) provided on October 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine provided on October 2, 2019.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says that this is not covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine provided on October 2, 2019.
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services you received on
August 23, 2019.
You asked the Plan to waive the copay for the services provided. You say that you did not know the provider
was associated with the hospital. The Plan denied your request. The Plan says the claim for services was
processed 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 $300
copay for surgery services in an outpatient hospital.
You have been asked to pay a $300 copay for the services provided. The services fall within the outpatient
surgery 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 outpatient surgery services
you received on August 23, 2019.
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. The Plan denied your request. The Plan says IRF admission is not
medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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. Our
physician reviewer found that the enrollee was medically stable with no recent neurological or orthopedic
events except a left hip fracture 3 months ago, managed non-operatively with no evidence of need for
supervision by PMR Physician or needs acute rehab nursing care. The enrollee may benefit from further
physical therapy (PT) and occupational therapy (OT) due to Dementia, but does not require an intensive
therapy program. IRF admission is not medically necessary based on her current functional status and medical
stability. Her needs can be addressed with PT and OT at home to train the family or custodial 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on February 26, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician service. You say that the services were rendered at a participating facility by a non-participating provider whom is employed by the facility. You also say that this service should be covered by the Plan.The Plan denied your request. The Plan says prior authorization was not obtained before the service was rendered to the enrollee. 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 forthe office visit provided on February 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on July 5, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four monitoring is considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.
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 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and part of a bundled payment. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on July 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the mammogram provided on October 10, 2019.
You asked the Plan to reduce the copayment for the mammogram. You say that you were told there would be a $40 copayment if the services were not rendered at a hospital. You say the cancer center is across the street from the hospital. 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 $90 copayment for diagnostic procedures and tests at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for the ultrasound.
You have been asked to pay a $80.89 copayment for the mammogram. The mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital.
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 reduce the copayment for the mammogram provided on October 10, 2019.
Your complaint about the hospital's unfair and deceptive billing practice 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 11, 2019 through September 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 11, 2019 through September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Myocardial Strain Imaging (0399T) provided September 17, 2019.
You asked the Plan to pay for the Myocardial Strain Imaging. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not payable as a separate line item.
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 0399T is not supported in the medical record. Specifically, National Correct Coding Initiative Coding Policy Manual states that CPT code 0399T is associated with an ASC Payment Indicator- Packaged service/item. The service cannot be paid as a separate line item. Based on this information, we decided that Medicare rules for coverage of the Myocardial Strain Imaging have not been met. Therefore, we decided that the Plan does not have to pay for Myocardial Strain Imaging (0399T) provided September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from September 6, 2019 to September 25, 2019.
You asked the Plan to waive the copayments for the wound care. You say that you disagree with the copayment. 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 $250 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room or outpatient surgery services. You have been asked to pay a $724.73 copayment for the wound care. The wound care falls within the "Outpatient Hospital Services" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
September 6, 2019
Wound care
$67.66
$250.00
$67.66
September 6, 2019
Wound care
$219.69
$250.00
$219.69
September 6, 2019
Wound care
$217.69
$250.00
$217.69
September 6, 2019
Wound care
$219.69
$250.00
$219.69
Total
$724.73
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 copayments for the wound care provided from September 6, 2019 to September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 10, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that you received a letter stating you would receive an eye exam for diabetes at no cost. You say you did not pay a copayment at the time of the visit. 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 $20 copayment for a medical eye exam. You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows you were seen for blurry vision in addition to the diabetic exam, which makes the eye exam medical in nature. The medical record also shows diagnosis of age-related cataracts and dry eye syndrome.
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 medical eye exam provided on October 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 23, 2019.
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 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 for the medical services provided to the enrollee by an out-of-network provider on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for auditory services provided on August 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for auditory services. You say that you have provided medical records to show the medical necessity of these services. 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 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 auditory services provided on August 22, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the ambulance service and ground mileage provided on October 2,
2019.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the hospice facility was
called after the enrollee was already in the facility. The Plan denied your request. The Plan says that the
enrollee became hospice eligible on October 2, 2019 and these services are the responsibility of Medicare for
reimbursement.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide a copy of the applicable hospice election form for this
case. Therefore, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that
the Plan has to pay for the ambulance service and ground mileage provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 25, 2018 by an out
of network (OON) provider.
You asked the Plan to pay for surgical service. You say that this provider is employed by a the hospital to
service medically necessary functions. The Plan denied your request. The Plan says the denial of payment for
this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 October 25, 2018
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on September 23, 2019.
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 the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the record. Specifically, the record does not indicate the presence of an independent trained observer. 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 (99152) provided on September 23, 2019.