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

We decided that the Plan does not have to pay for the office visit provided on January 18, 2021 by a non-participating provider.

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 rendered by a non-participating 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 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 visit provided on January 18, 2021 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 9, 2021 by a non-contracted provider.

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 rendered by a non-contracted 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 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 visit provided on February 9, 2021 by a non-contracted provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on November 18, 2020.

You asked the Plan to pay for the testing services. You say that physicians send specimens for testing. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The submitted claim lists the place of service as an independent laboratory. The records do not indicate the enrollee's specimen was obtained at an independent laboratory. 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 drug testing provided on November 18, 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 the IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different 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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF level of care.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 16, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 13. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 12, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you feel that you should not owe a copayment. 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 $35 copayment for each specialist visit. 

You had a specialist visit on March 12, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. 

You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 copayment for a specialist visit provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network
(OON) provider on April 7, 2021.

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 office visit (99204) rendered by the out-of-network (OON) provider on
April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 29, 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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).
You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that the enrolllee cannot use a standard compression device. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessories (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation and localized delivery of antimicrobial
agents provided on March 16, 2021 and gingival irrigation and application of desensitizing medicament
provided on March 18, 2021.
You asked the Plan to pay for the gingival irrigation, localized delivery of antimicrobial agents and application
of desensitizing medicament. You say that you were told that the services were covered by the Plan. You say
that you would not have authorized the work to be done if you were told it was not covered. The Plan denied
your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
gingival irrigation and localized delivery of antimicrobial agents provided on March 16, 2021 and gingival
irrigation and application of desensitizing medicament provided on March 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 home health aide visits.
You asked the Plan to pre-approve 8 home health aide visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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. 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 8 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs (advanced wound care, new ostomy care/teaching, frequent medication changes/teaching). Isolated lab draws are not in-and-of themselves considered a skilled service. The enrollee does not have documented skilled therapy needs. As such, home health aide services, which must be provided in conjunction with skilled nursing or skilled therapy services, are not shown to be medically necessary, reasonable or covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 home health aide visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from March 3, 2021, through March 17, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan has determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services 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 physical therapy services provided from March 3, 2021, through March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on March 16, 2021.
You asked the Plan to waive the copayment for an MRI. You say that the charges are very high and you cannot
afford them. 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 $0
copayment for mammograms and a $150 copayment for radiological diagnostic services.
You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic
services and related supplies benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI
provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that you were in an auto accident. You say that you
are not sure of the date. You also say that when you woke up, your dentures were missing. The Plan denied
your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency
limit has been reached.
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 and complete upper denture is not listed
as covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper
denture that you received on May 22, 2020. Therefore, we decided that the Plan does not have to pre-approve a
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and venipuncture provided on December 14, 2020 by an out-of-network provider.
You asked the Plan to pay for the office visit and collection of venous blood by venipuncture. You say that the enrollee came to your office in terrible pain so there was no time to discuss insurance information or request authorization. The Plan denied your request. The Plan says authorization was not obtained as required.
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 services 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 office visit and venipuncture provided on December 14, 2020
by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levalbuterol.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Levalbuterol.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure monitor.
You asked the Plan to pre-approve the monitor. You say that this is required to monitor your health and should be covered. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care and inpatient hospital services provided from October 11, 2020, to November 6, 2020.
You asked the Plan to waive the copayment for the emergency and inpatient care. You say that you are being billed $91,000 by the hospital, and they sent the bill to collections without notifying you. You are upset that the hospital is trying to bill you this amount when the Plan said you owe $1,890. The Plan denied your request. The Plan says the cost sharing has been applied correctly and you owe $1,890. The Plan has also reached out to the provider regarding the balance billing (the amount charged to you that exceeds what you are allowed to be asked to pay based on your contract) and has confirmed that the bill will be amended.
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 $90 copayment for emergency care and a $360 copayment for each of the first five days of an inpatient hospital stay. You pay $0 for days 6 to 90 of an inpatient admission. You have been asked to pay $1,890 for the emergency and inpatient care. You have been asked to pay $90 for the emergency care, and $360 for each of the first five days of your inpatient admission ($360 x 5 days + $90 = $1,890). 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 emergency care and inpatient hospital services provided from October 11, 2020, to November 6, 2020.
Your complaint about being balance billed by a Plan-contracted 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. Please note that it does appear that the Plan has already contacted the provider regarding this issue. If you continue to be asked to pay more than $1,890 for the services in question, you may contact the Plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.