Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services provided on October
21, 2020.

You asked the Plan to pay for the chronic care management services. You say that insurance initially paid on
the claim, but later recouped the payment. The Plan denied your request. The Plan says Original Medicare
would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's
terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the chronic care management services provided on October 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had
from February 18, 2021, to February 19, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you were in the hospital for four days
and upon discharge you told the hospital that your legs were swollen. You say you were discharged anyway
and then had to return because of this symptom. 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 $90
copayment for emergency room visits.

You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the service. 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 room (ER) visit you had from February 18, 2021, to February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedic
surgeon on March 24, 2021.

You asked the Plan to waive the copayment for the orthopedic surgery office visit. You say that you shouldn't
have to pay this copayment because you received a vaccine that hit the wrong spot in your arm. You said that
because this could cause muscle damage and because you have a sports/exercise business, this copayment
should 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 $45
copayment for specialist visits.

You have been asked to pay a $45 copayment for the orthopedic surgery office visit. This copayment applies
regardless of the reason for the 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 office visit you had with an orthopedic surgeon on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80307, 82962) provided on April 1,
2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied
your request. The Plan says this was not authorized.

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 laboratory services (80307, 82962) provided on April 1, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory services coded as 82947, 88305, J2704,
J3490, J7030 and 45385 provided on November 11, 2020, by an OON provider.

You asked the Plan to pay for the ambulatory services. You asked the Plan to please re-review and reprocess
this claim due to you being incorrectly denied. The Plan denied your request. The Plan says enrollees must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.

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 ambulatory services coded as 82947, 88305,
J2704, J3490, J7030 and 45385 provided on November 11, 2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient services provided on November 1, 2020.
You asked the Plan to waive the copay for the outpatient services. You say that you should be charged the copay amount for seeing a specialist. The Plan denied your request. The Plan says that you are responsible for the cost-share for these services.
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 copay for Medicare-covered services provided in an outpatient hospital. You have been asked to pay a $150 copay for the outpatient services. The outpatient services fall within the Medicare-covered services provided in an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the outpatient services provided on November 1,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient custodial care facility (99335) provided on February 8, 2021, by an out of network (OON) provider.

You asked the Plan to pay for established patient custodial care facility. You say that you believe that this claim may be payable under state law. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 established patient custodial care facility (99335) provided on February 8, 2021, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services represented by code 11056 provided on December 3, 2020.
You asked the Plan to pay for code 11056. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the Plan had previously paid for code 11056 on a different claim with the same enrollee, date of service, and provider. Therefore, we decided that the Plan does not have to pay for the podiatry services represented by code 11056 provided on December 3, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81201, 81321, 81405, 81406, 81408, 88237) rendered by the out of network (OON) provider on November 18, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 laboratory services (81201, 81321, 81405, 81406, 81408, 88237) rendered by the out of network (OON) provider on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 9 months rental of the requested home
ventilator (E0466).

You asked the Plan to pre-approve an additional 9 months rental of the requested home ventilator (E0466). You
say that the additional 9 months rental is medically necessary. The Plan denied your request. The Plan says the
additional 9 months rental is not medically necessary at this time. The Plan will approve 3 months to allow the
enrollee to demonstrate compliance and benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an additional 9 months rental of the
requested home ventilator (E0466). Our reviewer says that the additional 9 months rental is not medically
necessary at this time.

Our physician reviewer found an additional 9 months rental for the requested home ventilator is considered not
medically necessary. This enrollee has chronic obstructive pulmonary disease (COPD), but there is no
documentation of CO2 retention on an ABG. The ventilator is being used as BiPAP, which is not covered by
Medicare. Certain BiPAP devices can provide the AVAPS mode of ventilation that has been ordered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an additional 9 months rental of the requested home ventilator (E0466) have not
been met. Therefore, we decided that the Plan does not have to pre-approve an additional 9 months rental of the
requested home ventilator (E0466).
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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 that the patient was admitted for infected artificial knee joints and sepsis. Medical conditions are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy provided on January 1, 2020.
You asked the Plan to pay for massage therapy. You say that massage therapy should be covered the Plan. The
Plan denied your request. The Plan says massage therapy is not a covered service.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pay for massage therapy provided on January 1, 2020.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing services of a registered nurse (RN) in the home
health or hospice setting, each 15 minutes (G0299 x 11), occupational therapy services in the home health or
hospice setting, each 15 minutes (G0152 x 5), and the physical therapy services in the home health or hospice
setting, each 15 minutes (G0151 x 5) provided from June 26, 2020, to August 19, 2020.
You asked the Plan to pay for home health services. You say that the services were medically necessary. The
Plan denied your request. The Plan says that the records do not support the services that were provided on the
dates of service in this case. The Plan says that full medical records and notes were requested and not received.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health services. Our reviewer says that
the home health services are medically necessary. Our physician reviewer found the provided documentation
indicates that skilled nursing services and skilled therapy services were required to effectively provide
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a
maintenance program to maintain the patient's condition and/or prevent deterioration. Therefore, the reviewer
found that the home health services are considered medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to
pay for the skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15
minutes (G0299 x 11), occupational therapy services in the home health or hospice setting, each 15 minutes
(G0152 x 5), and the physical therapy services in the home health or hospice setting, each 15 minutes (G0151 x
5) provided from June 26, 2020, to August 19, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a disposable continuous glucose monitor (A9276).
You asked the Plan to pre-approve a disposable continuous glucose monitor. You say that this request is medically necessary. The Plan denied your request. The Plan says this device is non-covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor coded with A9276 is defined as a non-therapeutic continuous glucose monitor and statutorily non-covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a disposable continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a disposable continuous glucose monitor (A9276).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200, V2750, V2784) purchased on February 20, 2021.

You asked the Plan to pay for the eyeglasses. You say that you have benefits for these services, and they should be covered. The Plan denied your request. The Plan says the pages included with your appeal show information for a previous plan that terminated on December 31, 2020. You do not have vision benefits except for one routine eye exam each year and the Medicare-covered eyeglasses after cataract surgery. Routine eyewear is not covered by your current Plan.

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 does not cover routine eyewear, and only offers coverage for one routine eye exam each year. 

We looked at the file and the Plan's rules. Though the Plan offers a routine vision benefit in excess of Medicare coverage, eyewear is not covered under this benefit. The record does not indicate that this eyewear was purchased following cataract surgery. Based on this information, we decided that Medicare's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2200, V2750, V2784) purchased on February 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 12, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 12, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (97010, 98943, and
99213) provided on February 23, 2021.

You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the billed services are not
covered by Medicare or the Plan when provided by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the non-covered chiropractic services (97010, 98943, and 99213) provided on
February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on February 9, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the enrollee received a prescription, not emergency services.
Medicare says that plans must pay for emergency and urgently needed services.
The services at issue in this case would not be considered urgent or emergent. They cannot be covered based on Medicare or plan rules. 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 office visit services provided to the enrollee on February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspiration procedure for spinal surgery (20939).
You asked the Plan to pre-approve a bone marrow aspiration. You say that the requested treatment is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a bone marrow aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that bone marrow aspiration remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy for use as a bone graft extender or substitute.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspiration procedure for spinal surgery (20939).