Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on December 1, 2020, to December 18, 2020.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you were told that you would not owe anything for these services. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per day for days 1-20 for skilled nursing facility (SNF) care. You have been asked to pay a $20 copayment per day for days 1-17 for a skilled nursing stay. The total amount you are being asked to pay is $340 ($20 x 17 days = $340). The correct copayment has been applied to the services that were provided. A skilled nursing stay falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on December 1, 2020, to December 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on October 9, 2020.
You asked the Plan to pay for the ground mileage and ambulance service. 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 ground mileage and ambulance service provided on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames (V2020), deluxe lens feature (V2702), tint, photochromatic, per lens (V2744) anti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), Lens, polycarbonate or equal, any index, per lens (V2784), and vision supply, accessory and/or service component (V2797) provided December 28, 2020.

You asked the Plan to pay for the frames and lenses. You say that you have not exceeded your maximum allowance. The Plan denied your request. The Plan says eye wear was previously covered in 2019 therefore, the eye wear at issue is 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 once every 2 years.

We looked at the file and the Plan's rules. The Plan provided documentation that eye wear was previously covered by the Plan on November 4, 2019. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames (V2020), deluxe lens feature (V2702), tint, photochromatic, per lens (V2744) anti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), Lens, polycarbonate or equal, any index, per lens (V2784), and vision supply, accessory and/or service component (V2797) provided December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and imaging services provided on December 8, 2020 by a non-participating provider.
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 the services were rendered by a non-participating 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 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 office visit and imaging services provided on December 8, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on July 23, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an outpatient rehabilitation setting POS 57.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was billed with an office place of service code, but the record indicates that the member's face-to-face service was rendered in a non-residential Substance Abuse Treatment Facility. There is a more appropriate place of service code. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0483) provided on July 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 1, 2021.

You asked the Plan to pay for the comprehensive evaluation. You say that you saw a new dentist and this service was necessary. The Plan denied your request. The Plan says one comprehensive oral evaluation may be covered every three plan years. You had a comprehensive exam in August of 2019 that was covered by the Plan. This was less than 3 plan years ago.

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. The Plan says that one comprehensive oral evaluation may be covered every three plan years.

Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested in a frequency that is not covered under this benefit. Documentation shows that you last had this service less than three plan years ago. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on February 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
September 18, 2020, to September 25, 2020.

You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the claim was submitted with an invalid type of
bill code.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim was billed with an incorrect type of bill code. Therefore, we decided that the Plan does not
have to pay for the home health services provided to the enrollee from September 18, 2020, to September 25,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device (93296) provided on December 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the interrogation device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider did not obtain prior authorization as required by the plan benefits.

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 interrogation device (93296) provided on December 23, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for computed tomography (CT) scan of chest (71250) and test to measure expiratory airflow and volume changes before and after medication administration (94060) provided October 29, 2020.
You asked the Plan to waive the cost share for CT scan of chest and test to measure expiratory airflow and volume changes before and after medication administration. You say that you were not aware you would be charged for these services. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $10 copayment for diagnostic lab services and a $150 copayment for advanced imaging services. You have been asked to pay $93.31 which is less than the required $150 copayment for CT scan of chest and a $10 copayment for the test to measure expiratory airflow and volume changes before and after medication administration. CT scan of chest and test to measure expiratory airflow and volume changes before and after medication administration falls within the advanced imaging service and diagnostic lab service categories, respectively. 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 share for computed tomography (CT) scan of chest (71250) and test to measure expiratory airflow and volume changes before and after medication administration (94060) provided October 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services provided on September 20, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services do not allow for the CS modifier to be applied.
The Plan must follow Medicare rules. Medicare rules say that use the CS modifier on applicable claim lines to show the service is subject to the cost-sharing waiver for COVID-19 testing-related services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Specifically, the Centers for Medicare & Medicaid Services (CMS) provide a list of codes which are appropriate for the use of the CS modifier and the cost sharing waiver. The billed codes on this claim are not included on this list of approved codes. The CS modifier is not appropriate in this case. Therefore, we decided that the Plan does not have to pay for the emergency department services provided on September 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on September 5, 2020.

You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request.
The Plan says this denial of payment for this testing is correct, because this testing did not meet the Medicare
criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT
code 81479 for date of service September 5, 2020.

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding according to
Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have
not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on
September 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services provided on August 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the provided services. You say that the enrollee was a high-risk due to a previous breech. The Plan denied your request. The Plan says prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 file does not show that a referral was provided from the PCP. 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 ultrasound services provided on August 25, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session, 60 minutes (90837) provided on October 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no adequate time frame to obtain authorization for the service. The enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's 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 individual psychotherapy session, 60 minutes (90837) provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for duplex scan of extracranial arteries (93880) duplex scan of lower extremity arteries or arterial bypass grafts (93925) limited ultrasound study of arties of upper or lower extremity (93922) provided September 15, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you had radiology services on 9/15/2020 and the copayment should have been $20 but you are being charged $110. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $110 copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
You have been asked to pay $283.83 ($110 + $110 + $63.83) for the diagnostic services. For CPT code 93922 the allowed amount of $63.83 was less than the copay amount of $110, therefore, you are responsible for the lesser amount. The diagnostic services fall 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 duplex scan of extracranial arteries (93880) duplex scan of lower extremity arteries or arterial bypass grafts (93925) limited ultrasound study of arties of upper or lower extremity (93922) provided September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for multiple self-administered drugs provided during an outpatient hospital stay on September 4 to September 10, 2020.
You asked the Plan to pay for multiple self-administered drugs. You say that your outpatient status should have been changed to inpatient during your stay. The Plan denied your request. The Plan says the requested self-administered drugs are not covered under the Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for multiple self-administered drugs provided during an outpatient hospital stay on September 4 to September 10, 2020.
Benefits for multiple self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Your complaint about the hospital misclassifying you as an outpatient 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on October 7, 2020 by an out of network (OON) provider.

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 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 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 psychotherapy services provided on October 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on October 23, 2020, and November 24, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that you thought that all copayments were covered through 2020 and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist visits. You received specialist visits on October 23, 2020, and November 24, 2020. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on October 23, 2020, and November 24, 2020.