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

We decided that the Plan does not have to waive the copayment for the infusion services coded as 96365, 
96361, H1572 and 96366 provided October 9, 2020. 
 
You asked the Plan to waive the copayment for the infusion services. You say that you had no idea how much 
this was going to cost. No one told you how much it was going to cost. Then you found out that every day you 
go there, you would have to pay $700 as part of it. It's too much money. The Plan denied your request. The 
Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage. 
 
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% of 
the cost for all other Medicare covered Part B drugs for Medicare Part B prescription drugs.  
 
You have been asked to pay $728.27 for the infusion services. The infusion services fall 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 copayment for the infusion 
services coded as 96365, 96361, H1572 and 96366 provided October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing home visit and wound care services provided by an out of network (OON) provider.

You asked the Plan to pay for the OON medical services. You say that the care provided was medically necessary and should be covered. The Plan denied your request. The Plan says OON care was provided in a non-emergency situation without prior authorization. This is not covered by 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 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 nursing home visit and wound care services provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric admission.

You asked the Plan to pay for the inpatient admission. You say that the following is a summary of the denial from the Plan as well as substantiation of the medical necessity that supports the need for services as provided and billed. The Plan denied your request. The Plan says this request does not meet clinical criteria for an acute inpatient stay.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 hospital admission. Our reviewer says that based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety as the patient awaited placement.

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 hospital admission have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the integrated biopsychosocial assessment (90791).

You asked the Plan to pay for the integrated biopsychosocial assessment. You say that you did not receive proper notice of this enrollee's benefit determination, hence the untimely submission. The Plan denied your request. The Plan says the claim was submitted after the timely filing limitation.

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 the integrated biopsychosocial assessment was not filed until October 9, 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 integrated biopsychosocial assessment (90791).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided by an out of network (OON) provider.

You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient services 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 WATS 3D brush biopsy testing.

You asked the Plan to pay for the WATS 3D brush biopsy. You say that it is felt that this testing is medically necessary and is useful for management of the patient's condition. The Plan denied your request. The Plan says this is not found to be reasonable and necessary based on current literature.

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 pay for the WATS 3D brush biopsy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 65-year-old man with a history of Barrett's esophagus without Dysplasia. Specimen collection for WATS 3D testing. The case file contains a WATS 3D Biopsy Test Report. While it is speculated that WATS 3D biopsy testing can potentially improve the management and improve outcomes of patients with Barrett's esophagus and esophageal Dysplasia, there is not high-quality evidence in the medical literature demonstrating that such testing improves the management and outcomes of such patients. There are no medical records in the case file documenting that the requested testing was medically reasonable and necessary for the enrollee in this case.

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 WATS 3D brush biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D brush biopsy testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine 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 services are not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered.

Benefits for these services 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: Unfavorable

We decided that the Plan does not have to pay for the Glycated hemoglobin testing provided by an out of network (OON) provider.

You asked the Plan to pay for the OON Glycated hemoglobin testing. You say that you wish to appeal this denial because it should be covered. The Plan denied your request. The Plan says this service was provided and ordered by an OON physician. These services were not emergent and no prior authorization for OON care 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 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 Glycated hemoglobin testing provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015).

You asked the Plan to pay for an eye refraction. You say that coverage should be provided for the requested service. The Plan denied your request. The Plan says rules for payment have not been met because the requested service was not rendered as part of routine vision care provided by a Plan-preferred provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided as part of routine vision care provided by a Plan-preferred provider.

We looked at the file and the Plan's rules. In this case, the provider confirmed that the requested service was not provided as part of a routine eye exam but instead as part of a medical procedure distinct from routine vision care. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015).

You asked the Plan to pay for determination of refractive state. You say that you were seen for a diagnostic exam and you would like the plan to cover the service. The Plan denied your request. The Plan says your benefit for a routine eye examination was exhausted prior to the date of service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once per calendar year.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of determination of refractive state have not been met. Specifically, the service is a covered benefit, but the record indicates that you exceeded the frequency limit. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with suspension sleeve 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 there is no valid physician order or proof of delivery.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid physician order or proof of delivery for the DME. 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 knee orthosis with suspension sleeve rendered.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided by an out of network (OON) provider.

You asked the Plan to pay for the OON drug testing. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says the testing provided was not urgent/emergent and no authorization was requested for it to be provided OON.

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 drug testing 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 definitive urine drug testing (UDT).

You asked the Plan to pay for the definitive UDT. You say that it is felt this is medically necessary. The Plan denied your request. The Plan says the enrollee did not require definitive testing of the 15-21 drugs in this case.

The Plan follows Medicare rules. Medicare rules say that definitive UDT may be considered reasonable and necessary when the criteria listed in the Rules section have been met.

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 definitive UDT. Our reviewer says that the documentation does not support the need for this testing. Our physician reviewer found the enrollee has a history of diabetes, obesity, and low back pain. He is maintained on medical therapy including opiates. No specific rationale was given for the specific analytes tested in this case. The review has determined that the enrollee did not meet all of the criteria for coverage for the drug testing. It was not reasonable and medically necessary for the enrollee to have the drug testing.

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 definitive UDT have not been met. Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Arthrocentesis.

You asked the Plan to waive the copayment for Arthrocentesis (20610). You say that you were never told there
was a copay of this much that you would owe. The Plan denied your request. The Plan says you were charged
this copayment 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 $225
copayment for Outpatient Surgery.

You have been asked to pay a $225 copayment for Arthrocentesis. Arthrocentesis falls 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 copayment for Arthrocentesis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee.

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 services rendered by non-participating providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance supplies.

You asked the Plan to pay for the ambulance supplies (A0999). You say that the ambulance service was medically necessary because of your injury. The Plan denied your request. The Plan says the services are approved for payment, but the supplies cannot be billed separately.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Medicare rules say all services and supplies provided during an ambulance transport are covered under one billing code and each service and/or supply cannot be billed separately.

We looked at the file and Medicare rules. Code A0999 is an invalid code for Medicare purposes and cannot be billed separately. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies (A0999) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Ostomy supplies.

You asked the Plan to waive the coinsurance for the Ostomy supplies. You say that this coinsurance is a financial hardship for you. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for prosthetic devices and related supplies.

You have been asked to pay 20% coinsurance for the Ostomy supplies. The Ostomy supplies fall within the prosthetic devices 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 coinsurance for the Ostomy supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120), the cleaning, (D1110), and the protective restoration (D2940).

You asked the Plan to pay for the dental services. You say that you were under the impression that these services were covered by the plan. You say that you are on a fixed income. You also say that you cannot afford this bill. The Plan denied your request. The Plan says coverage for periodic oral exams is limited to 1 per calendar year. The Plan says that coverage for cleanings is limited to 1 per calendar year. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that protective restoration is not listed as a covered service.

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 and periodic oral exam and cleaning are listed as covered services, the frequency limits have been exceeded. The record shows that the Plan paid for these services. Additionally, protective restoration is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120), the cleaning, (D1110), and the protective restoration (D2940).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0156, S9122, T1021).

You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied your request. The Plan says records for this service have not been submitted.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We find that CPT codes G0156, S9122, and T1021are not supported in the medical record. Specifically, the submitted medical records do not include documentation of home health services being performed. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0156, S9122, T1021).