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

We decided that the Plan does not have to pay for the acupuncture services rendered.

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 provider type is not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The Plan covers acupuncture from a physician only.

We looked at the file and Medicare rules. The file shows that the acupuncture services were not performed by a physician. Based on this information, we decided that the Plan's rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services rendered.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cataract removal surgery (66984).

You asked the Plan to waive the deductible for the surgery services. You say that the deductible should have been applied to the facility and not the provider. You say that you have had this issue before, and it was corrected. The Plan denied your request. The Plan says in this case, the service at issue is subject to the deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for outpatient surgery services.

The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies to outpatient surgery services. This cost sharing is a contractual obligation that had not been met at the time the surgery services was received. Therefore, we decided that the Plan does not have to waive the deductible for the cataract removal surgery (66984).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing.

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 procedure code G0483 is 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 code G0483 is definitive drug testing, 22 or more drug classes.

We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of drug testing of 22 or more drug classes. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services.

You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 outpatient hospital services.
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. You say that you are alone and need assistance. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital for a total hip replacement. Your current nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your conditions are stable. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may benefit from further therapy, you do not require an intensive therapy program in an IRF.

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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says that the enrollee's care could have occurred safely in an observation setting.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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 suture removal (S0630).

You asked the Plan to pay for suture removal. You say that this is a payable code. The Plan denied your
request. The Plan says this code is not valid.

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 S0630 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of suture removal have not been met. Therefore, we
decided that the Plan does not have to pay for suture removal (S0630).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone marrow biopsy (38222).

You asked the Plan to waive the copayment for the bone marrow biopsy. You say that the copayment is too high. The Plan denied your request. The Plan says the copayment 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 $380 copayment for Medicare-covered outpatient surgery in an outpatient hospital setting or ambulatory surgical center.

You have been asked to pay a $380 copayment for the bone marrow biopsy. A bone marrow biopsy 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 the bone marrow biopsy (38222).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

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 not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed until November 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV) with battery.

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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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
you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a
personal mobility deficit that impairs your ability to complete mobility-related activities of daily living
(MRADLs) in the home, but the mobility deficit is helped by the use of a walker. There is no detailed home
assessment indicating that you can safely maneuver a POV in the home. The records state that the requested
device will not fit in your home. The criteria for coverage are not met and the POV is not reasonable or
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 a power operated vehicle (POV) with battery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection.

You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the coinsurance charge for Medicare Part B drugs. 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 20% coinsurance for Medicare Part B prescription drugs.

You received a Medicare Part B drug. The allowed amount is $832.50 and 20% of that is $166.50.

You have been asked to pay the total coinsurance amount of $166.50 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the visit to the emergency room and
subsequent inpatient stay.

You asked the Plan to waive the copayments for the emergency and inpatient care. You say that you did go to
the emergency room, but you were not admitted to the hospital and should not have these charges. The Plan
denied your request. The Plan says medical records were provided that show that you were admitted overnight
and released. The claim 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 $90
copayment for emergency care and a $250 copayment for each of the first seven days of an inpatient hospital
stay.

You have been asked to pay a $90 copayment for emergency care and a $250 copayment for a one-day
inpatient hospital stay. A visit to the emergency room falls within the emergency care benefit category, and
documentation was provided to show that you stayed an additional day in an inpatient setting. 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 visit to the emergency room and subsequent inpatient stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D assay (82306) and infectious agent detection (87798).

You asked the Plan to pay for the testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are not covered benefits.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D assay (82306) and infectious agent detection (87798).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam that was provided.

You asked the Plan to pay for the dental service. You say that you feel that 2 oral exams per calendar year is not enough. You say that you would like to have 3 to 4 exams covered per year. You also say that you feel that this oral exam should be covered. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 frequency limit of 2 oral exams per calendar year has been exceeded. The record shows that the Plan paid for oral exams. Therefore, we decided that the Plan does not have to pay for the oral exam that was provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid examination and selection (92590) hearing aid,
not otherwise classified (V5298).

You asked the Plan to pay for the hearing services. You say that weeks after getting your hearing aids, you
received a postcard from the plan indicting that hearing aid coverage was available and it listed the brand that
you had just bought. The Plan denied your request. The Plan says the services is not covered under the plan
benefits.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says
that routine hearing exams, hearing aids or exams to fit hearing aids are not covered under any condition.

We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage
of the hearing services have not been met. Therefore, we decided that the Plan does not have to pay for hearing
aid examination and selection (92590) hearing aid, not otherwise classified (V5298).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services.

You asked the Plan to pay for the chiropractic services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue is are manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care was medically necessary. The Plan denied your request. The Plan says that based on the records this might be an observation level of care.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.

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 acupuncture services.

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 provider type is not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more than twenty sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The Plan contract says that acupuncture is covered when provided by a physician.

We looked at the file and Plan's rules. The file shows that the services were not performed by a physician.
Based on this information, we decided that the Plan's rules for coverage of the acupuncture services have not
been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia service.

You asked the Plan to pay for the anesthesia service. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the provider submitted the claim with the wrong Place of Service and has
not submitted a corrected claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate POS code.

In this case the code 00410 cannot be paid as billed due to an error with the POS code reported. Based on this
information, we decided that Medicare rules for coverage of the anesthesia service have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia service.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says a network gap does not exist. It is not medically necessary to receive these services from an out-of-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician's services to be provided by the out-of-network provider.