Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatient mental health visits provided from April 2, 2020, to October 1, 2020.You asked the Plan to waive the copayments forthe outpatient mental health visits. You say that your copayments should be covered since an executiveorder included mental health telehealth visits were going to be covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms allcost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered individual or group therapy visit for Mental Health Specialty Services. You have been asked to pay a $40 copayment for each of the outpatient mental health visits. The outpatient mental health visits fall within the "Outpatient mental health care" benefit category. The record shows the Plan covered the telehealth mental health care visits. 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 haveto waive the copayments forthe outpatient mental health visits provided from April 2, 2020, to October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe observation or inpatient hospital care services (99235) provided July 31, 2019.You asked the Plan to pay forthe hospital services. You say that you did not receive proper notice of this enrollee's benefit determination hence, the untimely submission of the claim.The Plandenied your request. The Plan says the time limit for filing has expired.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the hospital services was not filed until 09/18/2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe observation or inpatient hospital care services (99235) provided July 31, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursementfor the progressive lenses (V2781 x 2), the eyeglass frames (V2020), and the deluxe lens feature(V2702) purchased on September 18, 2020.You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the items were purchased from an out of network provider; therefore, they are not payable.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.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these items have not been met.Specifically, the eyeglasses were purchased froma provider that does not participate inthe Plan's network.The Plan contract states that vision services and supplies rendered 
by an out-of-network provider are not covered or reimbursed by the Plan. Therefore, we decided that the Plan does not have to issue reimbursementfor the progressive lenses (V2781 x 2), the eyeglass frames (V2020), and the deluxe lens feature(V2702) purchasedon September 18, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forinfusion services (S9328) provided from February 6, 2020, to June 16, 2020.You asked the Plan to pay forthe infusion services. You say that the services were medically necessary.The Plan denied your request. The Plan says the billed code is not eligible for Medicare payment.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 S9328 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, CPT code S9328 is marked with a status of "I" which means it is invalid for Medicare billing. Based on this information, we decided that Medicare rules for coverage of the infusion services have not been met.Therefore, we decided that the Plan does not have to pay forinfusion services (S9328) provided from February 6, 2020, to June 16, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on September 25, 2020.You asked the Plan to pay forthese services. You say that you didn't know you had to use certain providers.The Plan denied your request. The Plan says the services are not covered from a non-network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules applyin this case. The Plan pays for hearing aids only from a network provider.We looked at the file and the Plan's rules. The file shows that you received hearing aids from a non-network provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on September 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran electrocardiogram (93010) provided on August 8, 2020.You asked the Plan to pay foran electrocardiogram. You say that this is a payable code.The Plan denied your request. The Plan says this is included in the emergency room visit.The Plan must follow Medicare rules. Medicare rules say that aprofessional component billing based on a review of the findings of an x-ray or an EKG procedure, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the serviceand would beincluded in the emergency department evaluation and management (E/M) payment.We looked at the file and Medicare rules. The submitted medical records do not include a complete writer report for the service at issue, meaning the conditions for separate payment have not been met. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay foran electrocardiogram (93010) provided on August 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe psychotherapy provided on September 1, 2020.You asked the Plan to reimburse you forthe psychotherapy provided by a mental health counselor. You say that you would like the Plan to reimburse you.The Plan denied your request. The Plan says the provider is not a Medicare qualified mental health care professional.The Plan must follow Medicare rules. Medicare rules say that mental health services and visits are only covered from certain types of health professionals. We looked at the file and Medicare rules. The services were not provided by a Medicare qualified mental health care professional. Based on this information, we decided that Medicare rules for coverage of psychotherapyhave not been met.Therefore, we decided that the Plan does not have to reimburse you forthe psychotherapy provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services (S9328) provided July 29, 2020 to September 2, 2020.You asked the Plan to pay forthe home infusion services. You say that the services were medically necessary.The Plan denied your request. The Plan says the billed code is not eligible for Medicare payment.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 S9328 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, CPT code S9328 is marked with a statusindicator of "I" which means it is not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion services (S9328) provided July 29, 2020 to September 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve 180 sessions of psychotherapy services (90837,90832,90834) and 60 sessions of psychiatry diagnostic evaluation (90791).
You asked the Plan to pre-approve the outpatient mental health services. You say that you would like reconsideration because these services are medically necessary. The Plan denied your request. The Plan says that these services may be rendered at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the record indicates that the Plan used clinical information to determine the medical necessity of the requested services. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pre-approve 180 sessions of psychotherapy services (90837,90832,90834) and 60 sessions of psychiatry diagnostic evaluation (90791).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 17, 2019.You asked the Plan to pay forthe transportation services. You say that the previously processed claim was not paid in accordance with the negotiated terms.The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until thefirst day of the month following the month in which hospice was revoked or discharged.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 November 14, 2019. The services in question were provided before the end of that month.Therefore, wedecided that the Plan does not have to pay forthe ambulance services provided on November 17, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on August 3, 2020 and August 16, 2020.
You asked the Plan to waive the copayments for the ambulance rides. You say that the enrollee was not given a choice of not going by ambulance and the family could have been taken him to the other hospital to avoid the ambulance charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per ride for Medicare-covered ground and air ambulance benefits (cost-sharing applies per one-way). The enrollee has been asked to pay a $225 copayment for each of the ambulance rides. The ambulance rides fall within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ambulance rides provided on August 3, 2020 and August 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on July 30, 2020.You asked the Plan to pay forthe testing services. The Plan denied your request. The Plan says that the documentation did not include a valid physician order or medical records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case,the CPT Code Manual definition of code 81445 is targeted genomic sequence analysis panelof 51 or greater genes. We find that CPT code 81445 is not supported in the medical record. Specifically, there is insufficient records to show that the ordered testingis diagnostic, prognostic or predictive;or clearly correlatesany test result with given interventions. 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 forthe genetic testing provided on July 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on May 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until October 21, 2020. This means that more than one calendar year from the date of service had passed before a claim wasfiled.Therefore, we decided that the Plan does not have to pay forthe services rendered on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesprovidedon July 15, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan mustpay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also 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 Plandid not pre-approve the physician's services.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 physician's services provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided October 6, 2020.
You asked the Plan to pay for the dental services. You say that you were told by a plan representative that you receive one free x-ray a calendar year. This was the only x-ray offered at this facility. The Plan denied your request. The Plan says this service is not covered under the plan 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 panoramic x-ray (D0330) provided October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information on pages 3-4 and 3-7 of the Plan's 2020 EOC.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance provided on August 12, 2020.You asked the Plan to pay forthe periodontal maintenance. You say that you were not advised that this provider was not qualified for reimbursement.The Plan denied your request. The Plan says the treating provider opted out of Medicare effective December 2, 2015 to December 2, 2021. The Plan also says thatThe Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance provided on August 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapy services (97110, 97140, 97530, 97535) provided January 23, 2020.You asked the Plan to pay forthe therapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the services billed.The Plan mustfollow 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, 97140, 97530, & 97535 are not supported in the medical record. Specifically, the record does not support CPT codes 97110 & 97140 were performed more than once on the same date of service. Payment was already issued for these services under a different claim. The record does not support the 6 units of 97530 & 97535 billed. Basedon this information, we decided that Medicare rules for coverage of the therapy services have not been met.Therefore, we decided that the Plan does not have to pay fortherapy services (97110, 97140, 97530, 97535) provided January 23, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided on August 18, 2020.You asked the Plan to pay forthe Guardant360 testing. You say that you would like reconsideration because all of the member's treatment options involve molecular testing.The Plan denied your request. The Plan says the documentation does not include enough clinical information to determine the medical necessity of this service.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 pay for the Guardant360 testing. Our reviewer says that the requested items/services are not considered medically reasonableand necessary in this case. Our physician reviewer found panel testing, inclusive of testing that is not related to colorectal cancer or for which there are no associated therapies, is not medically necessary or reasonable.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 Guardant360 testing have not been met.Therefore, we decided that the Plan does not have to pay forGuardant360 testing provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires, (e.g., apnea monitor), per pair (A4557) provided September 20, 2020.You asked the Plan to pay forthe lead wires. You say that please reconsider the claim for payment or provide documentation supporting decision.The Plan denied your request. The Plan says a TENS unit had been purchased April 20, 2020, which is within the 12 months and records supporting medical necessity of the additional lead wires was not submitted.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. Based on this information, we decided that Medicare rules for coverage of the leadwires have not been met.Therefore, we decided that the Plan does not have to pay forthe lead wires, (e.g., apnea monitor), per pair (A4557) provided September 20, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe imaging services rendered on March 12, 2020.You asked the Plan to waive the copayments forthese services. You say that the copayments are a financial hardship.The Plan denied your request. The Plan says the copayments were applied 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 $40 copayment for each basic imaging service and a $275 copayment for each advanced imaging service.Review of the file shows that you received an echocardiogram on March 12, 2020. You have been asked to pay a $40 copayment for these services. These services fall within the basic imaging service benefit category. This means that you have been asked to paythe correct amount based on your contract with the Plan. The file shows that you received a stress test on March 12, 2020. You have been asked to pay a $275 copayment for these services. These services fall within the advanced imaging service benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The total amount you have been asked to pay for these services is $315. 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 copayments forthe imaging services rendered on March 12, 2020.