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

We decided that the Plan does not have to pay for the office visit provided on November 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service should not be denied from an Indian health care provider. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 on November 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for administration of one (1) vaccine (CPT code 90471) and shingles vaccine (CPT Code 90750) provided to the enrollee on November 24, 2020.

You asked the Plan to pay for the services. You say that you do have a prior approval letter showing this vaccine would be covered at a 100% in office. The Plan denied your request. The Plan says Zoster vaccine is not covered as a preventative service by Medicare after the age of 18 years. The Plan states in cases where vaccination or inoculation is excluded from coverage, related charges are also not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the 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 services. Furthermore, since the immunization is not covered the administration of the vaccine (CPT Code 90471) is also not covered. Therefore, we decided that the Plan does not have to pay for administration of one (1) vaccine (CPT code 90471) and shingles vaccine (CPT Code 90750) provided to the enrollee on November 24, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for skin substitute graft services (CPT 15271) provided to the enrollee on December 17, 2020.

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 that the records do not support the services billed.

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 15271 is "Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area." 

We asked our coding 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 supported by the medical records. Our coding reviewer found the documentation supports that the graft was secured with a clean dressing. 

We looked at this coder's review, the file, and Medicare rules. 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 skin substitute graft services (CPT 15271) provided to the enrollee on December 17, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a complete intraoral series of radiographic images (D0210), and teeth cleaning (D1110) provided on October 14, 2020.

You asked the Plan to pay an additional amount for a comprehensive oral evaluation, a complete intraoral series of radiographic images, and teeth cleaning. You say that you thought the provider was in-network. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a complete intraoral series of radiographic images, and teeth cleaning have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a complete intraoral series of radiographic images (D0210), and teeth cleaning (D1110) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies above what is usually included in an office visit when performed during a public health emergency reported on September 23, 2020.

You asked the Plan to pay for the additional supplies. You say that the supplies medically necessary and should be covered. The Plan denied your request. The Plan says the supplies are included in payment for the other procedures provided.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B and is not recognized as a separately payable procedure. Based on this information, we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies above what is usually included in an office visit when performed during a public health emergency reported on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient assisted living visit (CPT code 99336) provided to the enrollee on December 2, 2020, by a non-participating provider.

You asked the Plan to pay for the services. You say that the provider depends on the hospital to get authorization. The Plan denied your request. The Plan says the services were provided at a non-participating assisted living facility. The Plan states the provider is not a network provider with the health plan. The Plan states the services were not referred by a network provider or rendered in a participating facility. The Plan states 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 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 established patient assisted living visit (CPT code 99336) provided to the enrollee on December 2, 2020, by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a respiratory assist device (E0471)
provided January 12, 2021.
You asked the Plan to waive the coinsurance for the respiratory assist device. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 20%
coinsurance for Durable Medical Equipment.
You have been asked to pay a 20% coinsurance for the respiratory assist device. The respiratory assist device
falls within the Durable Medical Equipment 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 respiratory assist device (E0471) provided
January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services from May 29, 2021 forward.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs continued inpatient psychiatric services. The Plan denied your request. The Plan says inpatient services from May 29, 2021 forward are not medically necessary.

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 pre-approve inpatient psychiatric hospital services beginning May 29, 2021. Our reviewer says that the services are not medically necessary. Our physician reviewer found the health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services from May 29, 2021 forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy (19083) performed January 7, 2021.

You asked the Plan to waive the copayment for the biopsy. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $200 copayment for outpatient surgical services.

You have been asked to pay a $200 copayment for the biopsy. The biopsy falls within the outpatient surgical 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 a biopsy (19083) performed January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81406) provided August 31, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The services provided were cardiovascular risk panels and are non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81406) provided August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses (V2020) purchased on February 2, 2021.

You asked the Plan to pay for the eyeglasses. You say that the Plan should pay the full $150 for the frames and you feel that it is unfair that they are not paying the full $150. You feel that the Plan should pay an additional $82.50. The Plan denied your request. The Plan says that this claim processed correctly. The Plan states that the total cost of the glasses was $250. You have a dental allowance of $150, which leaves you responsible for $100 for the frames. The Plan says that the provider wrote off $93.50 of the total cost, which is why the Plan paid $67.50. The Plan states this is correct because you owe $150 less than the total cost.

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 up to $150 per year for eyewear. 

We looked at the file and the Plan's rules. Documentation shows that the Plan paid $67.50 for the frames provided on February 2, 2021. The Plan states that the total cost of the frames is $250, and the provider wrote off $93.50, which the Plan applied to their portion of the payment. However, if the provider wrote off part of the cost of the item/service, then the gross amount billed should be where the write-off applies. This means that the total cost of the frames should be $156.50. The Plan also states that they will pay up to $150 for routine contact lenses and eyewear every year.

This means you should be held responsible for $6.50 as the remaining cost for the frames and the Plan should pay an additional $82.50. Based on this information, we decided that the Plan has not paid the full $150 allowance as agreed upon in the contract. Therefore, we decided that the Plan has to pay for the eyeglasses (V2020) purchased on February 2, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81551) provided December 29, 2020.
You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for Males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy. We looked at the file and Medicare rules. The record shows this genetic test was ordered before the results of the first biopsy were obtained. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81551) provided December 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the replacement nasal cushion provided on February 8, 2021.

You asked the Plan to waive the coinsurance for the replacement nasal cushion. You say that this is a duplicate claim, and the Plan has overpaid the provider. The Plan denied your request. The Plan says you have been asked to pay 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered item.

You have been asked to pay $6.51 which is 20% of the allowed amount for the replacement nasal cushion. The allowed amount is $32.55. ($32.55 x 20% = $6.51). The replacement nasal cushion falls within the "Durable medical equipment (DME) 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 replacement nasal cushion provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
December 14, 2020.

You asked the Plan to pay for the comprehensive evaluation. You say that you needed this type of evaluation
again because you switched to a new dentist. You did not know there was a frequency limitation, and you
cannot afford this cost. The Plan denied your request. The Plan says you had a comprehensive oral evaluation
in January 2020, which was covered by the Plan. The Plan can only pay for this service once every three plan
years.

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. The Plan can cover one
comprehensive oral evaluation every three plan years.

Though the Plan offers a dental benefit in excess of Medicare coverage, the evaluation is requested in a
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation (D0150) provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a hospital bed (E0303) provided February 11, 2021.

You asked the Plan to waive the coinsurance for the hospital bed. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable Medical Equipment.

You have been asked to pay a 20% coinsurance for the hospital bed. The hospital bed falls within the Durable Medical Equipment 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 hospital bed (E0303) provided February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) received January
29, 2021.

You asked the Plan to pay for the panoramic radiographic image. You say that your benefit includes x-rays,
therefore the requested service should be covered. The Plan denied your request. The Plan says your benefit
does not include panoramic radiographic image.

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. Your Plan benefit covers bitewing x-rays, which are different from
panoramic radiographic images. Therefore, we decided that the Plan does not have to pay for the panoramic
radiographic image (D0330) received January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Skilled Nursing Facility services September 3, 2020 to September 18, 2020.
You asked the Plan to waive the copayment for the Skilled Nursing Facility services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $100 copayment per admission for Skilled Nursing Facility services. You have been asked to pay a $100 copayment per admission for the Skilled Nursing Facility services. 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 Skilled Nursing Facility services September 3, 2020 to September 18, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the provided therapeutic apheresis on December 8, 2020.

You asked the Plan to pay for the provided therapeutic apheresis. You say that the provided therapeutic apheresis on December 8, 2020 was medically necessary. The Plan denied your request. The Plan says the provided therapeutic apheresis on December 8, 2020 did not meet criteria.

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 provided therapeutic apheresis. Our reviewer says that the provided therapeutic apheresis on December 8, 2020 did not meet criteria. Our physician reviewer found the review indicates that the enrollee underwent apheresis on December 8,2020 for hypercholesterolemia. The review has determined that the enrollee did not meet NCD criteria for the provided therapeutic apheresis on December 8, 2020.

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 provided therapeutic apheresis have not been met. Therefore, we decided that the Plan does not have to pay for the provided therapeutic apheresis on December 8, 2020.