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

We decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan provided on December 8, 2020.

You asked the Plan to pay for the PET/CT scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file, the Plan's contract and Medicare rules. We find that the PET/CT scan is not supported as billed. Specifically, this PET/CT scan was not billed with an appropriate diagnosis code per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the Positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on March 31, 2020.

You asked the Plan to pay for chronic care management (99490). You say that this claim was filed timely. The Plan denied your request. The Plan says you did not submit any documentation to support overriding the timely filing limit.

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 chronic care management (99490) was not filed until April 5, 2021. 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 chronic care management provided on March 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 5, 2021.

You asked the Plan to pay for the ambulance services. You say that your husband was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 5, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services provided on February 28, 2020.

You asked the Plan to pay for chronic care management services (99490). You say that the claim was timely. The Plan denied your request. The Plan says you did not submit any documentation to support overriding the timely filing limit.

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 chronic care management services (99490) was not filed until April 5, 2021. 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 chronic care management services provided on February 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for the ambulance services and emergency room services provided from December 10, 2020 to December 24, 2020.

You asked the Plan to waive the co-payments for the ambulance services and the emergency room services. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received ambulance services and emergency room services on the dates of service at issue in this appeal. The Plan says that the correct co-payments have applied per the enrollee's contract with the Plan.

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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 co-payment for Ambulance services and a $90 co-payment for Emergency care.

We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received ambulance services on December 10, 2020, December 21, 2020 and December 24, 2020. The enrollee has been asked to pay a $275 co-payment for each ambulance service. The ambulance services fall within the Ambulance services benefit category. The file also shows that the enrollee received emergency room services on December 24, 2020. The enrollee has been asked to pay a $90 co-payment for the emergency room services. The emergency room services fall within the Emergency care benefit category. This means that the enrollee has been asked to pay the correct amounts based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the co-payments for the ambulance services and emergency room services provided from December 10, 2020 to December 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for psychotherapeutic services (90791, 90832, 99402) received on December 28, 2020, and January 8, January 22, and January 28, 2021.
You asked the Plan to waive the copayments for psychotherapeutic services. You say that psychobehavioral therapy is a complete sham and you refuse to pay the resulting charges. The Plan denied your request. The Plan says the correct copayments were 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 $15 copayment for each individual/group Medicare-covered therapy visit.
You have been asked to pay a $15 copayment for each session of psychotherapeutic services. Psychotherapeutic services fall within the "Outpatient mental health 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 copayments for psychotherapeutic services (90791, 90832, 99402) received on December 28, 2020, and January 8, January 22, and January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 14, 2020, to December 17, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the out-of-network charges because the claims have never been processed this way in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for days 1-5 for in-network and out-of-network inpatient hospital care. 

You had an inpatient hospital stay from December 14, 2020, to December 17, 2020. Therefore, you are responsible to pay a $350 copayment for days 1-3 (December 14, 2020, to December 16, 2020). $350 (copayment) x 3 (inpatient days) = $1,050.

You have been asked to pay the total copayment amount of $1,050 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient 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 copayment for an inpatient hospital stay provided from December 14, 2020, to December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a percutaneous implantation of neurostimulator electrode array (63650) performed on February 6, 2019.

You asked the Plan to pay for a percutaneous implantation of neurostimulator electrode array. You say that the claim was filed timely. The Plan denied your request. The Plan says rules for payment have not been met.

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 a percutaneous implantation of neurostimulator electrode array was not filed until August 28, 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 a percutaneous implantation of neurostimulator electrode array (63650) performed on February 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for specialist services provided by a participating provider on January 19, 2021.

You asked the Plan to waive the co-payment for specialist services. You say that you saw a physician assistant. You say that your doctor passed away, so you had to find a new doctor. The Plan denied your request. The Plan says the correct co-payment has been 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 $35 co-payment for physician/practitioner services.

You have been asked to pay a $35 co-payment for specialist services. The physician who provided these services is considered a specialist; therefore, the correct co-payment has been applied. Specialist services fall within the physician/practitioner 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 co-payment for specialist services provided by a participating provider on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cancer screening testing provided on July 22, 2020.

You asked the Plan to pay for genetic testing. You say that the Plan must cover all Medicare-covered services, and no existing provider within the network can offer an equivalent service. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because predictive screening testing is not a Medicare benefit.

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 testing at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cancer screening testing provided on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on March 9, 2021 and April 5, 2021.

You asked the Plan to waive the deductible for the office visits. You say that this provider has been your primary care physician for a few years and her status has not changed. You say that you were told the office is in-network and payments should be reinstated. The Plan denied your request. The Plan says the deductible applied correctly.

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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visits were received on March 9, 2021 to April 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on March 9, 2021 and April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care/personal care services provided October 26, 2020 to December 28, 2020.

You asked the Plan to pay for the custodial care services. You say that skilled nursing was not necessary, but you could not be trusted at home alone and required a companion to work with you on brain exercises to enhance your cognitive and memory abilities. The Plan denied your request. The Plan says custodial care is not covered by the Plan.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered.

We looked at the file and the Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care services have not been met. Therefore, we decided that the Plan does not have to pay for the custodial care/personal care services provided October 26, 2020 to December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a peripheral nerve neurostimulator (64555).

You asked the Plan to pre-approve the implantation of a peripheral nerve neurostimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the implantation of a peripheral nerve neurostimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure would be experimental for the patient's condition.

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 implantation of a peripheral nerve neurostimulator have not been met.

Therefore, we decided that the Plan does not have to pre-approve the implantation of a peripheral nerve neurostimulator (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for IV hydration therapy, each additional hour (96361) antibody identification, titer and typing, RBC (86870) red blood cells, leukocytes reduced, each unit (P9016) provided January 8, 2021 to January 9, 2021.

You asked the Plan to waive the copayment for the blood transfusion services. You say that you feel that the in-network provider hospital admittance, that the doctor ordered should be covered. You are requesting a coding review and hope the Plan will cover the full cost of this hospital stay. The Plan denied your request. The Plan says the claim was processed with the correct cost shares 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% coinsurance for Medicare Part B covered drugs and $85 copayment for diagnostic procedures and tests at an Outpatient hospital. 

You have been asked to pay $324.11 (239.11 coinsurance and $850.00 copay) for blood transfusion services. The blood transfusion services fall within the Medicare Part B prescription drugs and Outpatient diagnostic tests and therapeutic services and 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 copayment for IV hydration therapy, each additional hour (96361) antibody identification, titer and typing, RBC (86870) red blood cells, leukocytes reduced, each unit (P9016) provided January 8, 2021 to January 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 9, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation
submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken
in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for
this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been
met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 9,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on November 10, 2020.

You asked the Plan to pay for the critical care services. You say that the medical records provided support that
payment is due for the services in dispute. The Plan denied your request. The Plan says the billed services were
not supported.

The Plan must follow Medicare rules. Medicare rules say that critical care is a time-based service, and for each
date and encounter entry, the physician's progress note(s) shall document the total time that critical care
services were provided.

We looked at the file and Medicare rules. The code billed for the services in dispute was 99291. The definition
of this code is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. The medical records provided do not show the time spent providing critical care services was
between 30 and 74 minutes. Based on this information, we decided that Medicare rules for coverage of the
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical
care services provided on November 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for diagnostic radiology services provided by a
participating provider October 17, 2020.

You asked the Plan to waive the co-payment for diagnostic radiology services. You say that you were total
shocked when you received this bill. The Plan denied your request. The Plan says the correct co-payment has
been 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 $160
co-payment for outpatient diagnostic tests/diagnostic radiology tests.

You have been asked to pay a $160 co-payment for each diagnostic radiology test. Two diagnostic tests were
performed; therefore, the total amount you are being asked to pay is $320 ($160 x 2 tests= $320). Diagnostic
radiology services fall within the outpatient diagnostic tests/diagnostic radiology tests 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 co-payment for diagnostic radiology services provided by a participating
provider October 17, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated in a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient's current medical condition does not require intensive physician or nursing supervision in an IRF. The patient may benefit from additional physical and occupational therapy, but the documentation does not show that this therapy must be on an intensive level 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.