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

We decided that the Plan does not have to pay for the ambulance response and treatment services provided on July 30, 2020, and August 28, 2020.

You asked the Plan to pay for the services provided. You say that you had emergencies that required an ambulance to take you to the emergency room. The Plan denied your request. The Plan says the service is not covered by Medicare.
The Plan must follow Medicare rules. 

The rules say that Medicare does not pay for ambulance services when there is no transport. 

In this case, the CPT Code Manual definition of code A0998 is ambulance response and treatment, no transport. The ambulance company did not provide transport services on July 30, 2020, or August 28, 2020. 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 response and treatment services provided on July 30, 2020, and August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement (11721) rendered by the out of network (OON) provider on August 6, 2020.

You asked the Plan to pay for this 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 service was rendered by an out of network provider, 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the nail debridement (11721) rendered by the out of network (OON) provider on August 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) care provided from March 11, 2020, to March 31, 2020.

You asked the Plan to pay for SNF care. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee revoked hospice on March 11, 2020 and therefore the Plan is not responsible for coverage until the first day of the following month.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on March 11, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) care provided from March 11, 2020, to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic eye examination provided on October 5, 2020.

You asked the Plan to waive the copayment for eye exam. You say that this was a routine exam and should not have a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $20 copayment for specialist eye exam. The record shows that this visit addressed non-routine issues, therefore it is considered to be a diagnostic eye exam with copayment and not a routine eye exam. 

You have been asked to pay $20 copayment for eye exam. Eye exam 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 for a diagnostic eye examination provided on October 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the diagnostic imaging services.

You asked the Plan to waive the copay for the services provided. You say that you received an office visit with a specialist. The Plan denied your request. The Plan says the claim processed 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 $100 copay for diagnostic tests. 

The file shows that you received a diagnostic mammogram. You have been asked to pay a $100 copay for the services provided. The services fall within the outpatient diagnostic 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 copay for the diagnostic imaging services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services rendered from August 25, 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 services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with other specified depressive disorder. Based on the submitted records, it was not expected that she would improve in a reasonable period of time, as she was not showing dangerousness to self or others and did not have hallucinations or aggressive behaviors. She was cooperative with care. The services were for the purpose of diagnosis or reasonably expected to improve her condition. The services were not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. 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 inpatient psychiatric services rendered from August 25, 2020 to August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided on July 1, 2020.

You asked the Plan to waive the copayment for specialist telehealth services. You say that you did not physically see the physician so you should not be responsible for a copayment. The Plan denied your request. The Plan says you were charged the copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Physician Services. 

You have been asked to pay a $45 copayment for specialist telehealth services. The specialist telehealth services fall within the Physician 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 specialist telehealth services provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider sees the enrollee at the facility's request. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 17, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency services provided on September 21, 2020.

You asked the Plan to pay for the emergency services. You say that the emergency services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on September 20, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the emergency services provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Durolane injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the guidelines do not list knee pain without osteoarthritis as a medically acceptable, evidence-based approved use.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 76 year old male with reported knee pain. Examination of the right knee was unremarkable and x-ray right knee was normal. A request for Durolane injection was made. As Durolane is not indicated or FDA-approved for use in knee pain without osteoarthritis, this request for such is not supported and will be considered not medically necessary at this time. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Durolane injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care office visit (99214) provided on August 23, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $50 copayment per visit for Medicare-covered urgently needed services. 

You have been asked to pay a $50 copayment for the urgent care office visit provided. 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 urgent care office visit (99214) provided on August 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on August 13, 2020.

You asked the Plan to waive the copay for the lab services. You say that you were stuck 4 times without success. The Plan denied your request. The Plan says the claim was processed 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 $10 copay for lab services. 

Although not all labs were able to be completed on the date of service at issue, some labs were able to be rendered. You have been asked to pay a $10 copay for the lab services. The lab services fall within the outpatient diagnostic 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 copay for the lab services provided on August 13, 2020.

Your complaint that there were multiple attempts to collect a blood sample is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 13, 2020 by an out of network provider.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request 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 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 the physician services provided on October 13, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85060) provided September 1, 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 the CPT code billed was not appropriately reported for the place of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 85060 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule. 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 (85060) provided September 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan. The requested LTACH services medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from February 3, 2020, through February 28, 2020.

You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider is ineligible. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. A search of the online Data.Medicare.gov and in Dialysis Facility Compare - Listing by Facility, by using the provider name, there are no active records is on file for this provider. Per the above guidelines we find the Medicare rule for payment of this February 03, 2020 through February 28, 2020, claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for the medical services provided from February 3, 2020, through February 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 and the manual therapy techniques services coded 97140 provided on July 21, 2020.

You asked the Plan to pay for the therapeutic procedure services and the manual therapy techniques 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 supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 97110 and 97140 are not supported in the medical record. Specifically, the medical records submitted do not provide a detailed description of the specific therapeutic exercises performed. In addition, the submitted medical records do not document the time spent performing the billed service distinct from other services billed on the billed date of service. Therefore, the billed code of 97110, units, and modifier cannot be verified. 

The submitted medical records do not document the time spent performing the billed service distinct from other services billed on the billed date of service. Therefore, the billed code of 97140, units, and modifier cannot be verified. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure services and the manual therapy techniques services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure services coded 97110 and the manual therapy techniques services coded 97140 provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 26, 2020 by an out of network provider.

You asked the Plan to pay for the physician services. You say that the service was medically necessary. The Plan denied your request. The Plan says you did not request 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 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 the physician services provided on October 26, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Testopel (J3490).

You asked the Plan to waive the coinsurance for the Testopel. You say that the service should be billed as an outpatient surgery. 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 20% coinsurance for chemotherapy and other covered Medicare Part B prescription drugs.

You have been asked to pay a coinsurance of $171.58 ($857.90 x 20% coinsurance) for Testopel. Testopel falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Testopel (J3490).