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

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 22,
2020.

You asked the Plan to waive the copayment for the ER visit. You say that you were informed no copayment
was needed to recheck the infection. You say that you shouldn't have to pay this bill. The Plan denied your
request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120
copayment for emergency care.

You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care"
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 ER visit provided on
November 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit and nail debridement provided by an out-of-network provider on March 4, 2020.

You asked the Plan to pay for the home visit and nail debridement. You say that authorization was impossible to obtain with the incorrect insurance information. You say that the patient required the medical care that was received, and the claim should be processed for payment. The Plan denied your request. The Plan says the provider is not a network provider with the Plan and prior 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 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 home visit and nail debridement provided by an out-of-network provider on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on December 9, 2020.

You asked the Plan to pay for the self-administered drug. You say that you believe this service should be
covered. The Plan denied your request. The Plan says your medical benefit does not cover self-administered
drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug
provided on December 9, 2020.

Benefits for the self-administered drug 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the telephone evaluation and management services (99443) provided on November 20, 2020.

You asked the Plan to pay for the telephone evaluation and management services.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that a member's home address is not an eligible originating site when billing telehealth services.

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. Specifically, the Plan's decision is based on the submitted claim being billed with an inappropriate address for location of services. The Plan has not forwarded a claim to verify the address that was used. Additionally, the Place of Service code billed is appropriate for telehealth services. It is the burden of the Health Plan to substantiate their denial with evidence. The Plan has not provided evidence in this case; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the telephone evaluation and management services (99443) provided on November 20, 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.
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 April 2, 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 April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on November 3, 2020.

You asked the Plan to pay for the office visit. You say that the claim should be reviewed for medical necessity and reprocessed for reimbursement. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and a non-network provider referred the member for 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 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 office visit provided by an out-of-network provider on November 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on December 17, 2020.

You asked the Plan to pay for the DME. The Plan denied your request. The Plan says there are no supporting office records.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records pertaining to the DME in question. Without supporting records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 21, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 21, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency and observation care provided to the enrollee from April 11, 2020, to April 14, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that outpatient charges cannot be carved out from the inpatient claim.

The Plan must follow Medicare rules. Medicare rules say that diagnostic services provided to a beneficiary 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.

We looked at the file and Medicare rules. The requested emergency care and observation care was provided within 3 days of the enrollee's admission. This means that it is appropriate to bill the requested services on the inpatient claim. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for the emergency and observation care provided to the enrollee from April 11, 2020, to April 14, 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64494 provided on October 5, 2020.

You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 code 64494 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 injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64494 provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. The device is considered experimental in nature and not medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing
facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee
does not meet criteria for coverage of continued inpatient skilled nursing facility care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 continued SNF care. Our reviewer says
that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found
that the enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee appears to
have reached a plateau in function, given her current weight bearing restrictions. Daily skilled services are not
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs, as a practical matter, can be provided at a lower level of 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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on December 28, 2020.

You asked the Plan to waive the copayment for an MRI. You say that you feel that you should only owe a $25
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, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175
copayment for advanced imaging services.

The record shows that you received an MRI on December 28, 2020, at an outpatient hospital facility.
Therefore, you are responsible to pay the $175 copayment.

You have been asked to pay a $175 copayment for an MRI. An MRI falls within the outpatient hospital
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 MRI provided on
December 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 4, 2020 to September 1, 2020.

You asked the Plan to pay for home health services. You say that these services should be covered. The Plan denied your request. The Plan says these services were not billed correctly.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, these services were not billed with the correct type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 4, 2020 to September 1, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry provided on April 14, 2020.

You asked the Plan to pay for Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) (88341). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the procedure is not eligible for payment to the same practitioner for the same patient on the same date of service.

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry provided on April 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services and does not have to waive the coinsurance for a wrist orthosis provided from October 29, 2020, to December 30, 2020.

You asked the Plan to waive the copayments for outpatient rehabilitation services and to waive the coinsurance for a wrist orthosis. You say that you disagree with the charges because you expected to only pay a $20 copayment per visit. 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, 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 for outpatient rehabilitation services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for durable medical equipment and related supplies. 

You received outpatient rehabilitation services from October 29, 2020, to December 30, 2020, for a total of 14 visits. Therefore, you are responsible to pay a $40 copayment per each visit. However, you are only being asked to pay $555.47, which is less than the total copayment amount. 

You received a wrist orthosis on October 29, 2020. The total allowed amount is $153.48 and 20% of that is $30.70. 

The total amount you owe is: $586.17.

You have been asked to pay the total amount of $586.17 for outpatient rehabilitation services and a wrist orthosis. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. A wrist orthosis falls within the durable medical equipment 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. Therefore, we decided that the Plan does not have to waive the copayments for outpatient rehabilitation services and does not have to waive the coinsurance for a wrist orthosis provided from October 29, 2020, to December 30, 2020.
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 19, 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 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on January 6, 2021.

You asked the Plan to pay for the psychotherapy. You say that you have been seeing this provider for over a year and you feel safe with her. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

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 psychotherapy provided by an out-of-network provider on January 6, 2021.