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

We decided that the Plan does not have to pay for physician services provided on November 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician 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 the member's primary care physician.
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 physician services provided on November 19, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 20, 2020 to August 31, 2020.

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 claims were billed incorrectly.

The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment.

We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 home health services rendered from August 20, 2020 to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on November 18, 2020.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.

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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjustable bed provided on July 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you purchased the bed to discontinue sleeping in a recliner after a stroke. The Plan denied your request. The Plan says the services were rendered without 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 the adjustable bed provided on July 22, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 12, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim for services denied correctly.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation. 

We find that the billed services area not supported in the record provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on December 10, 2020.

You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says you received the eyewear benefit was on December 22, 2018. That is when the rolling calendar year would start. You would not have been eligible for new eyewear until two years from that date of service, which would have been
December 22, 2020.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years.

We looked at the file and the Plan's rules. The file shows that you received the routine eyewear benefit on December 22, 2018 and you would have been eligible for eyewear on December 22, 2020. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from December 16, 2020, to December 24, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware the copayment was so high. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 copayment for each day for days 1-7 per admission and a $0 copayment each day for days 8-90 per admission for Medicare-covered inpatient hospital care. 

You have been asked to pay a $195 copayment for each day, days 1-7 of the inpatient hospital stay. ($195 x 7 = $1,365). The 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 the inpatient hospital stay provided from December 16, 2020, to December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on October 15, 2020.

You asked the Plan to pay for the assistant services. You say that the primary surgeon requested services from the assistant surgeon. The Plan denied your request. The Plan says the claim processed correctly.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered.

In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 27596. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on October 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the inpatient admission provided on January 11, 2021.

You asked the Plan to waive the co-payment for the inpatient admission. You say that you were in the hallway the entire time and should not be billed. 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 a $325 co-payment per day, days 1-5 for each Medicare-covered hospital stay.

You have been asked to pay a $325 co-payment for the inpatient admission. The inpatient admission falls within the "Inpatient hospital care" benefit category. The record shows you were considered inpatient. 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 the inpatient admission provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the global fee urgent care centers services coded S9083 provided on December 18, 2020.

You asked the Plan to pay for the global fee urgent care centers services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.

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 S9083 is global fee urgent care centers.

We find that CPT code S9083 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that these services are not payable. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the global fee urgent care centers services have not been met.Therefore, we decided that the Plan does not have to pay for the global fee urgent care centers services coded S9083 provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the specialist office visit on January 14, 2021.

You asked the Plan to waive the co-payment for the specialist office visit. You say that you were told there would not be a co-payment because this was a follow-up visit. 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 a $35 co-payment for each in-person specialist visit.

You have been asked to pay a $35 co-payment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 the specialist office visit on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on October 13, 2020.

You asked the Plan to pay for the orthosis. You say that the notes clearly document a detailed history. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. The Plan has indicated the enrollee was contacted via an unsolicited phone call regarding the provided orthosis. There is no documentation to show the enrollee provided written permission to make contact by telephone regarding the orthosis. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a semi-electric hospital bed and dry pressure mattress.

You asked the Plan to pre-approve a semi-electric (head and foot adjustment) hospital bed, with any type side rails, with mattress (E0260), dry pressure mattress (E0184). You say that the enrollee needs a semi-electric hospital bed and dry pressure mattress to relive severe dependent edema. The Plan denied your request. The Plan says that the record does not show the enrollee has need for a frequent and/or immediate change in position.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 a semi-electric (head and foot adjustment) hospital bed, with any type side rails, with mattress (E0260), dry pressure mattress (E0184). Our reviewer says that a semi-electric hospital bed is reasonable and medically necessary. Our physician reviewer found the patient's condition require position of the body in ways not feasible in an ordinary bed. A semi-electric hospital bed medically necessary for this patient. This enrollee has required a home health aide to assist with activities of daily living and due to her underlying medical condition, she has significant mobility limitations. She requires a hospital bed that would be able to elevate her head and assist with transfers and raise the foot of the bed to decrease her lower extremity edema.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric (head and foot adjustment) hospital bed, with any type side rails, with mattress (E0260), dry pressure mattress (E0184) have been met. Therefore, we decided that the Plan has to pre-approve a semi-electric hospital bed and dry pressure mattress.

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

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.We decided that the Plan does not have to pay for the Ferritin and Hemoglobin A1c lab testing provided on July 28, 2020.

You asked the Plan to pay for the lab services. You say that you processed the specimen and reported the findings to the referring physician. The Plan denied your request. The Plan says this lab testing is not Covid screening or testing.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. The lab services at issue are not indicated for the diagnoses listed on the claim. The 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 the Ferritin and Hemoglobin A1c lab testing provided on July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services and electrocardiogram (EKG) interpretation and report rendered on July 22, 2020.

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.

The Plan must follow Medicare rules. Medicare rules say that intra-operative and post-surgical services are included in the global surgical package. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.

We looked at the file and Medicare rules. Billed procedure code 99291 is not separately payable, as it was billed on the same date of service as a minor surgical procedure. Payment for these services is included in the global surgical package. Billed code 93010 (EKG interpretation and report) is a column II code with a modifier indicator of 1 when billed with column I code 12032. Code 93010 was not billed with an appropriate modifier to allow for separate payment. 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 critical care services and electrocardiogram (EKG) interpretation and report rendered on July 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an outpatient surgery provided by a participating provider on January 18, 2021.

You asked the Plan to waive the co-payment for an outpatient surgery. You say that you thought you already paid this. You say that they tried to get a kidney stone out and could not. 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 $325 co-payment for outpatient surgery/in-network.

You have been asked to pay a $325 co-payment for an outpatient surgery. The correct co-payment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network 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 an outpatient surgery provided by a participating provider on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora root canal (D3330) provided on November 18, 2020.

You asked the Plan to pay for the root canal. You say that this was an emergency procedure due to discomfort and infection.The Plan denied your request. The Plan says dental services are not covered when they are received from providers who have opted out of Original Medicare. The provider you saw does not participate in Medicare, therefore these services cannot be 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, services cannot be covered when they are received from a provider who has opted out of Medicare.Therefore, we decided that the Plan does not have to pay fora root canal (D3330) provided on November 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on February 4, 2021.

You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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, we have confirmed that code 99223 for the initial hospital care services has a bundled relationship with code 99236 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 30, 2020.

You asked the Plan to pay for foot orthotics. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the outpatient visit provided on January 28, 2021.

You asked the Plan to waive the co-payment for the outpatient visit. You say that you thought telehealth visits were waived. 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 a $20 co-payment for each individual or group therapy visit for Medicare-covered outpatient mental health services.

You have been asked to pay a $20 co-payment for the outpatient visit. The outpatient visit falls within the each "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 co-payment for the outpatient visit provided on January 28, 2021.