Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92012) provided January 17, 2020.
You asked the Plan to pay for the eye exam. You say that the service should be covered. The Plan denied your
request. The Plan says vision services provided out-of-network are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when provided by network providers.
We looked at the file and the Plan's rules. The services were provided out-of-network without preauthorization.
Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met.
Therefore, we decided that the Plan does not have to pay for an eye exam (92012) provided January 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
February 4, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says payment for this service is the
responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore,
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
February 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided March
13 to March 15, 2020.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment 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 a $120
copayment for Emergency Care.
You have been asked to pay a $120 copayment for the Emergency Room Services. The Emergency Room
Services fall within the Emergency 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 Emergency Room Services provided March 13 to March 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond
May 27, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee would benefit from
continued daily skilled therapy. The Plan denied your request. The Plan says the enrollee no longer requires
daily skilled care to either improve or maintain his condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 88 year
old male with dementia, depression, Crohn's disease and right hip dislocation admitted to the SNF. From a
nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was
alert with confusion. He had an ED visit for hip dislocation as he walked to the bathroom without wearing his
knee immobilizer. Regarding rehabilitation services, the beneficiary received PT, ST and OT in the SNF. By
the dates in question, the beneficiary was at a contact guard assist level with functional mobility including gait
to 300 feet. She required varying assist with ADLs. He tolerated a regular diet and thin liquids. He had ongoing
cognitive impairment.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a
skilled nursing facility setting.
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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care beyond May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 29, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 10, 2019, and December 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these services.
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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on December 10, 2019, and December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network
services 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 has network providers
available who can provide 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 medical services provided to you by an out-of-network provider on
October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided February
11, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should
be waived. The Plan denied your request. The Plan says the correct copayment 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 a $150
per day copayment for days 1-5 for inpatient care.
You have been asked to pay a $150 copayment for the inpatient hospital care. 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 care provided February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from
May 25, 2019 through May 29, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the stay was 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 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 inpatient mental health care. Our physician
reviewer found based upon review the records provided it was not expected this enrollee would improve in a
reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or
others, auditory or visual hallucinations and without aggressive behaviors. It did not appear medically
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a
lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory
or visual hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric
services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in
question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or
visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did
not appear that the services for the dates in question were reasonably expected or medically necessary to
improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized
treatment plan found in the record. It appears that the services were supervised and evaluated by a physician.
Based upon review the records provided, this patient does not meet the criteria for treatment in an acute
inpatient mental health treatment beyond the date in question of May 25, 2019 forward and could have been
treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or
visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and
compliant while not showing any acute threats to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient mental health care provided to the enrollee from May 25, 2019 through
May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on January 9,
2020.
You asked the Plan to waive the deductible for laboratory services. You say that you disagree with the charges
and want to know why the Plan did not pay or the charges. 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. Your
contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic
services and supplies.
You received laboratory services provided on January 9, 2020. The record shows that you had only paid
$218.10 toward the $300 deductible prior to receiving the services. Therefore, you are responsible to pay the
total allowed amount of $77.98.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services
and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services
was received on January 9, 2020. Therefore, we decided that the Plan does not have to waive the deductible for
laboratory services provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services (S9500) provided from December
7, 2019, to December 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Code S9500 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the
home infusion services (S9500) provided from December 7, 2019, to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on November 4, 2019.
You asked the Plan to waive the copayment for an epidural injection. You say that you have never been charged in the past and disagree with the charges. 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received an epidural injection on November 4, 2019 provided at an outpatient hospital facility. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for an epidural injection. An epidural injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 epidural injection provided on November 4, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a screening mammography (77067) provided on December 18, 2019.
You asked the Plan to pay for the screening mammography. You say that you would like reconsideration as this
service was billed correctly. The Plan denied your request. The Plan says that the modifier used is not
appropriate for a bilateral code.
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 asked our coder 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 the screening mammography. Our reviewers says that the
code for screening mammograms (77067) includes both breasts. In order to indicate that the code was only
partially completed (one breast), the 52 modifier was attached. Our reviewer found in order to indicate which
breast was imaged (left), the LT modifier was attached. The documentation supports that the services were
provided as billed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the screening mammography have been met. Therefore, we decided that the
Plan has to pay for a screening mammography (77067) provided on December 18, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 10, 2018 through November 14, 2018.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on November 10, 2018 and discharged on November 14, 2018. You were asked to pay a $265 copayment per day from November 10, 2018 through November 13, 2018, days 1-4 of your inpatient hospital care. You were discharged on November 14, 2018 and there was no copayment charge for the day of discharge. Per your contract there is a $265 copayment per day required for days 1-6. 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 care from November 10, 2018 through November 14, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided during hospital care on October 22, 2019 to October 24, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are not eligible for coverage under the Part B medical benefit.
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 pay for the self-administered drugs provided during hospital care on October 22, 2019 to October 24, 2019.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 20, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 has network providers
available who can provide 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 specialist services provided on January 20, 2020
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 (L0650) provided to the enrollee on
September 25, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on September 25, 2019.