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

We decided that the Plan does not have to pay for a nursing facility discharge day management service (99315) provided on January 31, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a facility discharge management service. You say that the provider is a hospitalist physician and depends upon the hospital staff to verify eligibility and obtain authorization. You also say that the services were medically necessary. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a nursing facility discharge day management service (99315) provided on January 31, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the procedure you had to remove a central
venous access device at an outpatient ambulatory surgery center on January 28, 2021.
You asked the Plan to waive the copayment for the outpatient procedure. You say that you were not charged
for this service in 2019. The Plan denied your request. The Plan says you were charged this copayment
correctly. The Plan says that your copayment was not correctly assessed in 2019, which is why you were not
charged that year.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for ambulatory surgery visits.
You have been asked to pay a $200 copayment for the outpatient procedure. The outpatient procedure falls
within the ambulatory surgery 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 copayment for
the procedure you had to remove a central venous access device at an outpatient ambulatory surgery center on
January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies provided from January 6, 2021, to February 8, 2021.

You asked the Plan to pay for infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) (A4223). You say that the medication was medically necessary based on the physician's recommendations. The Plan denied your request. The Plan says the drug was not received with an infusion pump, the drug is not listed in the Local Coverage Determination (LCD) 33794 as a covered drug and the claim had a GY modifier.

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 GY modifier is added to claims in which the item or service is statutorily excluded, does not meet the definition of any Medicare benefit, or is not a contract benefit. Home infusion therapy is covered when an infusion pump is used. Based on this information, we decided that Medicare rules for coverage of infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately) (A4223) have not been met. Therefore, we decided that the Plan does not have to pay for infusion supplies provided from January 6, 2021, to February 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on April 1, 2021, to April 15, 2021.

You asked the Plan to waive the copayment for a skilled nursing stay. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been 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 $0 copayment per day for days 1-20. There is a $100 copayment per day for days 21-100 for skilled nursing facility (SNF) care.

You have been asked to pay a $0 copayment per day for days 1-20 (March 9, 2021, to March 29, 2021). There is a $100 copayment per day for days 21-35 (April 1, 2021, to April 15, 2021) for a skilled nursing stay. The total amount you are being asked to pay is $1,400 ($100 x 14 days = $1,400). The EOC states that a benefit period begins on the first day you go to a Medicare-covered inpatient hospital or skilled nursing facility (SNF). The benefit period ends when you haven't been an inpatient at any hospital or SNF for 60 calendar days in a row. a skilled nursing stay falls within the skilled nursing facility (SNF) 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 skilled nursing stay provided by a participating provider on April 1, 2021, to April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency ambulance services provided January 12, 2021.
You asked the Plan to pay for the emergency ambulance services. You say that you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the claim has denied correctly.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the emergency ambulance services provided January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214, 94760) provided on March 24, 2021.
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 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 (99214, 94760) provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from March 25, 2021, to March 28, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that there was no reason for you to be admitted for this long considering that you had surgery later as an outpatient. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that as a courtesy, it has waived the copayment for one of the inpatient days, leaving you with a copayment of $550.
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 $275 copayment per day for days 1-5 for inpatient hospital care.
You have been asked to pay a $275 copayment per day for the inpatient hospital services. This copayment applies regardless of the reason for the length of your stay. 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 inpatient hospital services you received from March 25, 2021, to March 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99215) provided on February 24,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a telehealth office visit. You say that you want the Plan to pay for the service.
The Plan denied your request. The Plan says out-of-network telehealth visits are not covered.
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 a telehealth office visit (99215) provided on
February 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on November 6, 2020.

You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the enrollee indicated that she never received the billed item and does not know the ordering provider and there is no proof of delivery in the submitted records.

The Plan must follow Medicare rules. Medicare rules say that signed proof of delivery is required for billed DMEPOS items.

We looked at the file and Medicare rules. The delivery form submitted in the records has not been signed by the enrollee to validate delivery of the item billed on this claim. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis provided on November 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
You asked the Plan to pre-approve the additional PT visits. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the additional physical therapy visits are not medically necessary and the enrollee did not meet Medicare coverage criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The documentation does not reveal significant deficits that require formal therapy, and the enrollee can transition to an independent home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits (97164).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the external electrocardiographic recording you
received on April 7, 2021.
You asked the Plan to waive the copayment for the external electrocardiographic recording. You say that you
did not know there would be a copayment for this service. The Plan denied your request. The Plan says that
you were charged this 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 says that you pay a $0 copayment for
basic radiological services in your PCP's office or a $50 copayment if received in a freestanding radiological
facility.
We looked at your case file. In this case, you received external electrocardiography recording. You were
provided with a monitor to wear to record your heart. According to your contract, the copayment that would
apply for this type of service is based on the location where the service is rendered. The Plan contends that this
service was rendered at a freestanding radiological facility. However, there is no evidence of that in the case
file the Plan provided to us. The Provider of service is physically located in Texas, while you reside in South
Carolina. That clearly indicates that you were provided this monitor at a different location than the billing
provider themselves. The Plan has provided no evidence as to where, physically, you were provided these
services. Considering that some places of service have a $0 copayment for basic radiological services, the Plan
has not met its burden of proving that the location where you had this service is one for which a copayment is
due. That is why the copayment charged is not appropriate in this case. Therefore, we decided that the Plan has
to waive the copayment for the external electrocardiographic recording you received on April 7, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a physical
medicine specialist on April 29, 2021.

You asked the Plan to waive the copayment for the telehealth specialist visit. You say that the pandemic is not
over, so you believe this copayment should still be waived. The Plan denied your request. The Plan says you
were charged this 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 $25
copayment for telehealth visits with a specialist.

You have been asked to pay a $25 copayment for the telehealth specialist visit. 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 telehealth visit you had with a physical medicine specialist on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the anti-clotting management for patient taking warfarin (93793) provided from January 6, 2021, to March 26, 2021.

You asked the Plan to waive the copayment for the anti-clotting management for patient taking warfarin. You say that you would like the copayment waived for these claims. The Plan denied your request. The Plan says the copayments have processed 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 $15 copayment for physician/practitioner services. 

You have been asked to pay a total cost share less than the required $15 copayment for the anti-clotting management for patient taking warfarin. This service falls 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 copayment for the anti-clotting management for patient taking warfarin (93793) provided from January 6, 2021, to March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (99214) and follow-up evaluation conducted at least every three months during opioid therapy (G9562) on January 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit and follow-up evaluation during opioid therapy. You say that you have been treating this enrollee since 2013 and were not aware at the time of service that enrollee had recently gotten new insurance. You have since obtained a referral for subsequent services. The Plan denied your request. The Plan says this service was provided OON 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 office or other outpatient visit for the evaluation and management of an established patient (99214) and follow-up evaluation conducted at least every three months during opioid therapy (G9562) on January 27, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient psychiatric services provided from September 12, 2020, to April 3, 2021.

You asked the Plan to pay for the outpatient psychiatric services. You say that you would like these claims reimbursed. The Plan denied your request. The Plan says the provider type is not eligible for payment from the Medicare program.

The Plan must follow Medicare rules. Medicare rules say that a licensed professional counselor is not eligible for payment from Medicare. 

We looked at the file and Medicare rules. In this case, the provider that you received services from is a licensed professional counselor and is not eligible for payment from Medicare according to the Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient psychiatric services provided from September 12, 2020, to April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. 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 pre-approve foot orthotics