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

We decided that the Plan does not have to pay for physical therapy services provided on January 13, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical 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 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 physical therapy services provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating hospital on January 28, 2020.You asked the Plan to waive the copayment for outpatient hospital services. You say that you went to an office, not a hospital. The Plan denied your request. The Plan says the correct copayment has been 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 $325 copayment for outpatient surgery/in-network/other services. You have been asked to pay $114.20 which is less than your copayment amount of $325 for outpatient hospital services. The physician who provided these services is associated with a hospital; therefore, the correct outpatient hospital services copayment has been applied. Outpatient hospital services falls within the outpatient surgery/in-network/other services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating hospital on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on July 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the an ophthalmology visit (99204) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network ophthalmology visit. You say that you do not want to see another ophthalmologist in the plan's network. The Plan denied your request. The Plan says these services are not emergent or pre-authorized. There are multiple in-network providers available that can provide the same services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the an ophthalmology visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 10, 2019.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services billed with code 99051 provided on March 17, 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99051 (service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service). This code has a status indicator of B and no separate payment under Medicare. Therefore, we decided that the Plan does not have to pay for the services billed with code 99051 provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on August 15, 2019.
You asked the Plan to pay for the definitive drug testing. You say that this testing was medically necessary and should be paid. The Plan denied your request. The Plan says there is no valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. In this case, there is an order form in the file that indicates the custom profile. However, this order is not signed by the provider. Furthermore, no progress note was submitted to show intent for this testing to be performed. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.You asked the Plan to pay for foot orthotics. You say that the orthotics are medically necessary for you. You say that it is painful for you to walk even short distances and the orthotics have helped you be able to walk further than before. You asked the Plan to reconsider providing coverage for the orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 26, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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.
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 service 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 a domiciliary, rest home visit provided on February 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 22, 2020 to February 24,2020.You asked the Plan to waive the copayment for the SNF stay. You say that you should not be responsible for 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20 for in-network Medicare-covered services for each benefit period and a $178 copayment per day for days 21-100 for in-network Medicare-covered services for each benefit period. The enrollee has been asked to pay a $1,958 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay provided from January 22, 2020 to February 24, 2020.Your complaint that the provider should not have allowed your wife to sing the documentation 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on December 18, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 remains not supported
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the testing order forms were submitted, including a list of ordered tests, however, the enrollee's name was not included on the forms. Additionally, no form from December 18, 2019 was included. 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 pay for drug testing services (HCPCS G0483) provided to the enrollee on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services needed in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eye refraction services (92015) provided March 13, 2020.
You asked the Plan to pay for the refraction services. You say that you are requesting reconsideration of the denial of payment. The Plan denied your request. The Plan says that Medicare does not cover eye refraction for eyeglasses.
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 eye refraction and dilation when completed as a part of a routine eye exam. We looked at the file and the Plan's rules. The health plan contract, on page 89-90, says the Mandatory Supplemental Vision Benefit includes 1 routine eye exam per calendar year. The eye exam includes refraction and dilation. The plan has not provided records to support that the refraction service was not a part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction services have been met. Therefore, we decided that the Plan has to pay for the eye refraction services (92015) provided March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings diabetic insert (butler stick) identified with code E1399.
You asked the Plan to pre-approve the butler stick insert for stocking. You say that you require the stick to get the compression stockings on. The Plan denied your request. The Plan says this is a convenience item and therefore not covered.
The Plan must follow Medicare rules. The rules say that items not mainly for the convenience of the patient are covered. The butler stick insert for pulling the stockings on is a convenience item, and therefore not covered. 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 pre-approve compression stockings diabetic insert (butler stick) identified with code E1399.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 24, 2019.
You asked the Plan to pay for lab test. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the outpatient hospital Place of Service (POS) code was billed on this claim however the enrollee was a hospital inpatient at the time of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the Place of Service (POS) code for inpatient, off-campus outpatient hospital, or on-campus outpatient hospital respectively. We looked at the file and Medicare rules. This testing was performed on an enrollee who was a hospital inpatient at the time of service. Therefore, the Place of Service (POS) code 22 - indicating an on-campus outpatient hospital setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on February 20, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray and lab work provided by an in-network hospital facility on January 28, 2020 to January 31, 2020.
You asked the Plan to waive the copayment for an x-ray and lab work. You say that you were never informed about these charges. The Plan denied your request. The Plan says the correct copayments have been 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 $95 copayment and a $40 copayment for outpatient diagnostic tests/basic radiological/outpatient hospital and outpatient diagnostic tests/lab services/outpatient hospital. You have been asked to pay less than your copayment amounts of a $95 for an x-ray and a $40 copayment for lab work. The total amount you are being asked to pay is $104.31 ($79.81 (x-ray) + $24.50 ($lab work) = $104.31). An x-ray falls within the outpatient diagnostic tests/basic radiological/outpatient hospital and lab work falls within the outpatient diagnostic tests/lab services/outpatient hospital 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 an x-ray and lab work provided by in-network hospital facility on January 28, 2020 to January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on March 13, 2020.
You asked the Plan to waive the copayment for urgent care visit. You say that you tried to go to your primary care physician but then would not take you, so you feel that the $10 primary care copayment or $20 specialist copayment would be more appropriate. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $50 copayment for urgent care visit. You have been asked to pay $50 copayment for urgent care visit. urgent care visit falls within the Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit provided on March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete series x-rays (D0210) oral/facial photographic images (D0350x4) provided January 6, 2020.
You asked the Plan to pay for the dental services. You say that you were told before your services were rendered that they accepted your plan and they were an active participating plan provider. You have since found out that this is not the case. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for complete series x-rays (D0210) oral/facial photographic images (D0350x4) provided January 6, 2020.