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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis or an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is 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 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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar fusion. 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. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) and the bone replacement graft for ridge preservation (D7953) received June 24, 2020 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you have dental coverage and the Plan should pay a portion of the cost. The Plan denied your request. The Plan says part of the claim processed in your $100 deductible. The remaining service is denied as non-covered.
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 bone replacement graft for ridge
preservation (D7953) is not among those covered under this benefit. The Plan has a $100 deductible before coverage begins. When you receive services from an out-of-network provider the Plan processes payment based off the in-network negotiated rate. The Plan's allowed amount for the extraction was $92.50. This amount fell entirely within the Plan's $100 deductible. When you receive services from an out-of-work provider you may be charged more by the out-of-network provider. You may be responsible for the difference between what was charged by the out-of-network provider and the Plan's allowed amount. This is a cost sharing obligation you agreed to when you signed up for the Plan. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) and the bone replacement graft for ridge preservation (D7953) received June 24, 2020 from the out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the beneficiary is at a supervision/stand by
assist level with functional mobility and does not require skilled nursing or therapy services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership purchased November 1, 2020. You asked the Plan to pay for the gym membership. You say that you think the Plan should provide reimbursement equal to the cost of a fitness program membership. The Plan denied your request. The Plan says you are eligible for a membership at a participating fitness program facility with a $0 copayment. There is no other coverage for gym memberships under your benefit. The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits with a $0 copayment for participating fitness program gyms. The Plan's rules for coverage of gym benefits have not been met because your membership is not at a participating fitness program facility. Therefore, we decided that the Plan does not have to pay for the gym membership purchased November 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided February 5, 2021. You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford the ambulance bill. The Plan denied your request. The Plan says the copayment has been 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 $250 copayment for Medicare covered ambulance services per one-way trip, ground or air. You have been asked to pay a $250 copayment for the ambulance services. This service falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis (20610) and the hospital outpatient clinic visit (G0463) provided on February 10, 2021. You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided. 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 in-network Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $275 copayment ($106.74 +$168.26) for the in-network Medicare-covered surgery and clinic visit provided at an outpatient hospital. 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 arthrocentesis (20610) and the hospital outpatient clinic visit (G0463) provided on February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9502) provided January 14, 2021 to January 20, 2021.
You asked the Plan to pay for the 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 S9502 is not supported in the medical record. Specifically, per the 2021 National Physician Fee Schedule, this CPT code has a status of "I" which means it is invalid for Medicare purposes. 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 for home infusion services (S9502) provided January 14, 2021 to January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), laboratory service (86580), non-invasive ear or pulse oximetry for oxygen saturation (94760), service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to the basic service (99051), brief emotional/behavioral assessment (96127), and the annual depression screening (G0444) rendered by the out of network (OON) provider on February 12, 2021. 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 office visit (99203), laboratory service (86580), noninvasive ear or pulse oximetry for oxygen saturation (94760), service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to the basic service (99051), brief emotional/behavioral assessment (96127), and the annual depression screening (G0444) rendered by the out of network (OON) provider on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral supplies rendered on October 9, 2020 to November 7, 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 there is no valid proof of delivery. The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the enteral supplies rendered on October 9, 2020 to November 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation (A0428, A0425) and the emergency room visit received January 22 and February 3, 2021.
You asked the Plan to waive the copayments for the ambulance transportation and emergency room visit. You say that the Plan should pay for these services. The Plan denied your request. The Plan says the correct cost share applied to the claims.
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 $325 copayment for Ambulance Services, and a $90 copayment for Emergency Care. You have been asked to pay less than a $325 copayment for each ambulance transportation, and a $90
copayment for the emergency room 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 copayments for the ambulance transportation (A0428, A0425) and the emergency room visit received January 22 and February 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on May 28, 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 procedure code 97110 is not supported.
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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the
services were performed in the home setting and there is a more appropriate code for these services.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on May 28,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a consultation.
You asked the Plan to pre-approve an out-of-network consultation. You say that you can receive better care from the requested provider. The Plan denied your request. The Plan says the Plan has qualified providers who can evaluate your condition and provide another opinion.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a consultation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on July 7, 2020.
You asked the Plan to pay for the occupational therapy. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services to confirm if Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
occupational therapy have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation services rendered from December
25, 2020 to December 27, 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 procedure code 99356 is not supported.
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 99356 is prolonged service in the inpatient or observation
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for
inpatient or observation Evaluation and Management service).
We find that CPT code 99356 is not supported in the medical record. Specifically, there is no documentation of
30 minutes or more of prolonged services in the inpatient or observation setting. Based on this information, we
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the
Plan does not have to pay for the prolonged evaluation services rendered from December 25, 2020 to
December 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit (99307) provided on November 18, 2020, by an out of network (OON) provider.
You asked the Plan to pay for a SNF visit. You say that the facility failed to obtain necessary authorization for this patient. You also say the physician provided medically necessary services. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network 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. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit (99307) provided on November 18, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography provided on March 26, 2021.
You asked the Plan to pay for the computed tomography, head or brain; without contrast material (70450). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this procedure is bundled to another service billed on the same day by a physician under the same specialty in the same group.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The service was not billed with the correct modifier. Therefore, we decided that the Plan does not have to pay for the computed tomography provided on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses deluxe frames (V2025), and progressive lens per lens (V2781) provided April 2, 2021.
You asked the Plan to pay for the deluxe frames and progressive lenses. You say that a Plan representative told you the eyeglasses would be covered. The Plan denied your request. The Plan says the eyeglasses were provided out-of-network and therefore 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 a network provider. We looked at the file and the Plan's rules. In this case the frames and lenses were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses deluxe frames (V2025), and progressive lens per lens (V2781) provided April 2, 2021.
Your complaint about potentially receiving misinformation from a plan representative 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.