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

We decided that the Plan does not have to waive the copayment forthe diagnostic eye exam (92012) provided on October 7, 2020.You asked the Plan to waive the copayment forthe eye exam. You say that you should not have a copay because there is no copayment required for a glaucoma screening.The Plan denied your request. The Plan says the provider's office stated that this was not a glaucoma screening as you were already diagnosed with glaucoma. The service was billed as a general ophthalmic exam provided by a specialist's office. Eye exams provided by a specialist have a $40 copay.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 diagnostic vision exams provided by a specialist. You have been asked to pay a $40 copayment for an eye exam. This eye exam was provided by a specialist and was not billed as a glaucoma screening. Theeye exam falls within the diagnostic vision exams provided by a specialist 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 forthe diagnostic eye exam (92012) provided on October 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services (G0299) provided on May
18, 2019.
You asked the Plan to pay for the direct skilled nursing services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says home health agencies are to use
one of two institutional claim formats to bill Original Medicare which is CMS-1450, also known as the UB-04.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules say that these providers are required to use the electronic HIPAA standard institutional claim transaction,
the 837I. The minority of providers that are eligible for an exception to electronic claim submission use the
paper Form CMS-1450, also known as the UB-04.
We find that CPT code G0299 is not supported in the record. Specifically, these services have not been billed
on an appropriate institutional claim form. Based on this information, we decided that Medicare rules for
coverage of the direct skilled nursing services have not been met. Therefore, we decided that the Plan does not
have to pay for the direct skilled nursing services (G0299) provided on May 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the replacement power module for use with an electric or pneumatic ventricular assist heart device, the replacement battery clips for either an electric or pneumatic ventricular assist heart device, the replacement shower cover for either an electric or pneumatic ventricular assist heart device, a replacement battery for either an electric or pneumatic ventricular assist heart device and an accessory or replacement part for a ventricular assist heart device provided on September 22, 2020.
You asked the Plan to waive the coinsurance for these items. You say that you should not have to pay this because you were not advised of the costs. The Plan denied your request. The Plan says that the coinsurance 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 20% coinsurance for durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for these items. These items fall 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 power module for use with an electric or peneumatic ventricular assist heart device, the replacement battery clips for either an electric or pneumatic ventricular assist heart device, the replacement shower cover for either an electric or pneumatic ventricular assist heart device, a replacement battery for either an electric or pneumatic ventricular assist heart device and an accessory or replacement part for a ventricular assist heart device provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you could easily tolerate three hours of rehabilitation a day.The Plan denied your request. The Plan says your needs could be met at a lower level of care.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID-19 pneumonia and your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computed tomography (CT) scan head or brain (70450) provided on September 23, 2020.You asked the Plan to waive the copayment forthe CT scan head or brain. You say that you would like this copayment waived.The Plan denied your request. The Plan says the copayment has applied correctly in this case.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 complex radiology. You have been asked to pay a total cost share of $206.43 for the CT scan head or brain which is less than the required $225 copayment. The service provided falls within the complex radiology 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 forthe computed tomography (CT) scan head or brain (70450) provided on September 23, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Part B drug and the clinic visit provided on April 6, 2020.You asked the Plan to waive the cost share forthe Part B drug and the clinic visit. You say that the Plan stated that you are not responsible for this amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each in-network Medicare-covered Part B drug and a $20 copayment for specialist for each in-network outpatient clinic visit. You have been asked to pay $680.36 which is 20% of the allowed amount for the Part B drug. The allowed amount is $3,401.82. ($3,401.82 x 20% = $680.36). You have also been asked to pay a $20 copayment for the clinic visit. The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. The clinic visit falls within the "Outpatient hospital 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 cost share forthe Part B drug and the clinic visit provided on April 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endosteal implant provided on June 12, 2020.You asked the Plan to pay forthe endosteal implant. You say that this implant was necessary after an emergency extraction.The Plan denied your request. The Plan says this procedure is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe endosteal implant provided on June 12, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable nebulizer provided on March 3, 2020.
You asked the Plan to pay for a portable nebulizer. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 portable nebulizer. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a portable nebulizer provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2020 and October 16, 2020.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Planauthorizes use of out-of-network providers.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 withthe Plan. The Plan did not pre-approve the physician's services.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 physician's services providedon October 9, 2020 and October 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe thigh treatment fracture (27238) provided on June 22, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the record provided does not support the service 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 27238 is the closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation. We find that CPT code 27238 is not supported in the medical record. Specifically, the record indicates the procedure name performed; however, a detailed noteof the service providedhas not been included. Without sufficient details of the service performed, the procedure cannot be verified. Additional records were requested, however were not provided. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forthe thigh treatment fracture (27238) provided on June 22, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on October 8, 2020.You asked the Plan to waive the copayment forthe laboratory work. You say that would like the copayment dismissed because this bloodwork was needed for the annual wellness visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is considered diagnostic in nature.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 forthe laboratory work provided on October 8, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing services (81226, 81479, 81225, 81227) provided on July 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON genetic testing services. You say that you were told to have these tests to see your medication tolerance.The Plan denied your request. The Plan says these tests 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 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 forthe genetic testing services (81226, 81479, 81225, 81227) provided on July 12, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services providedfrom June 14, 2020, through June 24, 2020.You asked the Plan to pay for the SNF 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 careand 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 contractwith 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 withthe Plan. The Plan did not pre-approve the SNF services. 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 SNF services providedfrom June 14, 2020, through June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires rendered on September 15, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than every 12 months would rarely be reasonable and necessary.We looked at the file and Medicare rules. The file shows that the TENS device was rendered on June 15, 2020; July 15, 2020; and August 15, 2020. Replacement lead wires more often than every 12 months is notnecessary.Therefore, we decided that the Plan does not have to pay forthe lead wires rendered on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe complete upper denture (D5110) and the complete lower denture (D5120) provided on September 1, 2020.You asked the Plan to reimburse you forthe dental items. You say that your daughter called about your coverage. You say that she was advised by a plan representative that dentures were covered. You say that your daughter called the dental office and was advised that they took your insurance and the dentures would be covered in full. You also say that you are on a fixed income and paid out of pocket for the services with the expectation that you would be reimbursed.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental items and services that you receive out of network are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.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, dental items and services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to reimburse you forthe complete upper denture (D5110) and the complete lower denture (D5120) provided on September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on November 16, 2020.You asked the Plan to waive the copayment forthese services. You say that you have never been charged a fee like this.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 $600 copayment per visit for in-network outpatient surgery. Review of the file shows that you received a cystoscopy on November 16, 2020. Per the contract with the Plan, there is a $600 copayment per visit for in-network outpatient surgery. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $548.22. Given that the allowed amount was less than the $600 copayment, you have been asked to pay $548.22 for these services.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiagnostic eye exam (90214) provided on July 15, 2019.You asked the Plan to waive the copayment fordiagnostic eye exam. You say that the service should be covered.The Plan denied your request. The Plan says the cost share 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 $25 copayment for vision care. You have been asked to pay a $25 copayment for diagnostic eye exam. This service falls within the vision 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 fordiagnostic eye exam (90214) provided on July 15, 2019