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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
September 15, 2020, to October 14, 2020.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF
services. The Plan denied your request. The Plan says the 100-day SNF benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from April 17, 2020, to
September 14, 2020. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pay for the skilled nursing facility (SNF) services provided from September 15, 2020, to
October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (92015) provided October 16, 2020.

You asked the Plan to pay for the refraction services. You say that this provider was referred to you by your optometrist. He had to perform the refraction in order to perform cataract surgery. Please reconsider the payment. The Plan denied your request. The Plan says refractive services are only covered when performed by a participating provider and performed as a routine vision exam.

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 performed by a participating provider and performed as a routine vision exam.

We looked at the file and the Plan's rules. Refractive services are only covered when performed by a participating provider and performed as a routine vision exam. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services (92015) provided October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and sleeve (L2397) provided on
September 4, 2020.
You asked the Plan to pay for a knee brace and sleeve. You say that the items are medically necessary. The
Plan denied your request. The Plan says there is insufficient documentation submitted for this case.
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 a knee brace and sleeve. Our reviewer says
that the requested items are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient
credible objective documentation of joint laxity.
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 knee brace and sleeve have not been met. Specifically, there is insufficient
documentation to support the medical necessity of a knee brace. A knee sleeve is not separately payable when
the base item is not covered. This means the items requested are not medically necessary and cannot be
covered. Therefore, we decided that the Plan does not have to pay for a knee brace (L1833) and sleeve (L2397)
provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth visit (99214) provided on October 20, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the telehealth visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided without a referral and did not meet OON criteria for coverage.
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 telehealth visit (99214) provided on October 20, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80305) provided on May 4, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the diagnosis does not support the drug testing.
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 a valid physician order or lab requisition stating exactly which testing was to be performed. 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 (80305) provided on May 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance supplies (A0422) provided on September 19,
2020.
You asked the Plan to pay for ambulance supplies. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that supplies are considered part of the general
ambulance service and payment for them is included in the payment rate for the transport.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of ambulance supplies have not been met. Therefore, we decided that the Plan does not have to pay
for ambulance supplies (A0422) provided on September 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

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 October 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided to the enrollee by an out-of-network provider on October 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 30, 2020.
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 June 30, 2020. 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 June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical implantation of neurostimulator electrode array.

You asked the Plan to pay for surgical services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is on the Medicare preclusion list and is not payable.

The Plan must follow Medicare rules. Medicare rules say that a Plan may not pay for items or services furnished to an enrollee by an individual or entity included on the Medicare preclusion list.

We looked at the file and Medicare rules. The rendering provider was included on the Medicare preclusion list for this date of service and is therefore not payable. Based on this information, we decided that Medicare rules for coverage of surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical implantation of neurostimulator electrode array.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided on October 9, 2020.
You asked the Plan to waive the copayment for a duplex scan. You say that you were not aware of the charges and cannot afford them. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 copayment for each radiological diagnostic service. You have been asked to pay the allowed amount of $148.87, which is less than the $160 copayment for a duplex scan. A duplex scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a duplex scan provided on October 9, 2020.
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. The Plan denied your request. The Plan says coverage criteria 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 physician reviewer found that the enrollee was admitted to the acute care hospital for a diabetic foot infection and had right below the knee amputation. Her medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound.

You asked the Plan to waive the copayment for an ultrasound. You say that this should be considered an abdominal aneurysm screening. 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 $60 copayment for ultrasounds.

You received an ultrasound. An ultrasound is not included in an abdominal aneurism screening. Therefore, you are responsible to pay the $60 copayment.

You have been asked to pay a $60 copayment for an ultrasound. An ultrasound falls within the outpatient hospital 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 an ultrasound.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics panel (81406, 81408 and 81479).

You asked the Plan to pay for the pharmacogenomics panel. You say that you would like reconsideration because this testing can affect clinical decisions on a patient's substance use that affects other medical conditions, pharmacotherapy, especially with controlled substances. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the pharmacogenomics panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics panel (81406, 81408 and 81479).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test.

You asked the Plan to pay for the drug test. The Plan denied your request. 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 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 Plan did not pre-approve the drug test. 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 a drug test.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the diagnostic testing services.

You asked the Plan to waive the cost shares for the services provided. You say that you are being billed for 2 scans. The Plan denied your request. The Plan says the cost share was 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 $150 copay for each Medicare-covered radiological diagnostic service.

The file shows that you received a duplex scan of the extremity veins. You were charged a $150 copay. You also received a limited duplex scan of the extremity veins. You were charged $100.48 for this test. Because the amount is less than your $150 copay, you were charged the lesser amount. You have been asked to pay a copay for each Medicare-covered radiological diagnostic service. The services fall within the outpatient diagnostic tests 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 cost shares for the diagnostic testing services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says these services were self-referred. The Plan says that there are in-network providers available 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 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 psychotherapy services provided on December 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Urology office visit (99214).

You asked the Plan to waive the copayment for the office visit. You say that you are not sure if you were charged the correct copayment. The Plan denied your request. The Plan says the copayment was 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 $25 copayment for each Medicare-covered specialist visit.

You have been asked to pay a $25 copayment for the office visit. This visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the Urology office visit (99214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 30, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you received a letter from the Plan stating you would not owe anything in 2020. 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 $265 copayment for ambulance services. You received ambulance services on September 30, 2020. Ambulance services are not included in the waiver. Therefore, you are responsible to pay the $265 copayment. You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental retainer crown, pontic, and core buildup.
You asked the Plan to pay for dental services. You say that you were given two options by the provider and
selected one, then over a month later were told it was not covered. The Plan denied your request. The Plan says
the denial of payment for these services is correct, because these dental services are not 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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental
retainer crown, pontic, and core buildup.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies provided by an out of network (OON) provider.

You asked the Plan to pay for medical supplies. You say that these services and supplies were provided in good faith. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these supplies could have been provided in-network.

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 medical supplies provided by an out of network (OON) provider.