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

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require daily skilled nursing or skilled 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 the SNF admission have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eyeglass fitting (92341) and eyeglasses (V2020, V2200) provided on February 1, 2021.

You asked the Plan to pay for the eyeglasses and fitting. You say that the enrollee's care is coordinated by the nursing home, and the enrollee does not have control over who provides care. The Plan denied your request. The Plan says eyeglasses will only be covered when they are received from a provider in the specified vision network. In addition, the spectacle fitting is not listed as covered under this benefit or by Medicare.

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 they are received from a provider who participates in the Plan's specified vision network. 

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network, and the fitting is not listed as a covered service under the routine vision benefit. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and fitting have not been met. Therefore, we decided that the Plan does not have to pay for an eyeglass fitting (92341) and eyeglasses (V2020, V2200) provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for total electric hospital bed (E0265) purchased December 28, 2020.
You asked the Plan to pay for total electric hospital bed. You say that a hand crank bed would not allow you to be independent and would require someone to be there to assist you when moving in and out of bed. The Plan denied your request. The Plan says a total electric hospital bed is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for total electric hospital bed (E0265) purchased December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99152 provided on September 23, 2020.
You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99152 provided on September 23, 2020.
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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not contain evidence that moderate sedation was performed with the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99152 provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 19, 2020.
You asked the Plan to pay for the dental services. You say that you would like to appeal these services. The
Plan denied your request. The Plan says you have reached your annual dental maximum.
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 Plan offers a $3,000 annual
maximum dental benefit. The record shows that you met the annual maximum benefit while processing this
claim for the December 19, 2020 date of service and your annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the dental services provided on December 19,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation services (G0378, 99285) provided on January 5, 2021, to January 7, 2021.

You asked the Plan to waive the copayment for outpatient hospital observation services. You say that you had an involuntary bowel movement and should not be required to pay a cost share. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $225 copayment for outpatient hospital observation.

You have been asked to pay a $225 copayment for outpatient hospital observation services. The EOC confirms $225 is the required copayment for this 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 outpatient hospital observation services (G0378, 99285) provided on January 5, 2021, to January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70482) provided on January 27, 2021.
You asked the Plan to pay for a CT scan. You say that this should be paid separately because the two scans were used to look at different things. The Plan denied your request. The Plan says this is not separately payable.
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, we have confirmed that code 70482 has a bundled relationship with code 70470 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70482) provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office or other outpatient visit (99214) provided on January 28, 2021, by an out of network (OON) provider.
You asked the Plan to pay for office or other outpatient visit. You say that this request was medically necessary. 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 office or other outpatient visit (99214) provided on January 28, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on January 26, 2021 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. 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 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 skilled nursing services provided on January 26, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive (92004) provided March 31, 2021.

You asked the Plan to waive the copayment for the comprehensive diagnostic eye exam. You say that you believe you should have a $0 copayment for your eye exam. The Plan denied your request. The Plan says the eye exam was not routine in nature and therefore the copayment for the eye exam was assessed appropriately.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Medicare-covered exams to diagnose and treat diseases of the eye.

You have been asked to pay a $40 copayment for the comprehensive diagnostic eye exam. the comprehensive diagnostic eye exam falls within the Vision 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 the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive (92004) provided March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L3960, L0650) November 25, 2020.

You asked the Plan to pay for the orthoses. You say that these items were medically necessary. The Plan denied your request. The Plan says the items were provided following an unsolicited telehealth consult with no physical exam. Coverage rules are not met.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. 

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L3960, L0650) November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 30, 2021.
You asked the Plan to pay for this service. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 chiropractic services provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2781, V2784, V2025) purchased on February 8, 2021.

You asked the Plan to pay for the eyeglasses. You say that you did not expect to pay this much, and you would have seen a different provider if you had realized the cost. The Plan denied your request. The Plan says your vision benefits were applied correctly.

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 up to $150 per year. 

We looked at the file and the Plan's rules. The provider billed the Plan $320 for the eyeglasses. The Plan covered $150 of this cost and was able to provide you with an additional discount. You are being asked to pay $136. ($320 - $136 = $184 of the cost that the Plan covered or discounted). This means that you have been asked to pay the correct amount based on your contract. Therefore, we decided that the Plan does not have to pay an additional amount for the eyeglasses (V2781, V2784, V2025) purchased on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 8, 2021.

You asked the Plan to waive the copayment for the office visit. You say that this was a pre-op visit and there was never any request for a copayment. You say that this is not a justifiable charge as pre-op and post-op services are included in a major surgical procedure. The Plan denied your request. The Plan says the copayment 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 provider and professional services at an in-network specialist's office.

You have been asked to pay a $25 copayment specialist's office. the office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a pre-operative 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 office visit provided on February 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) central line placement (36556) electrocardiogram (93010) endotracheal intubation (31500) provided September 23, 2020.
You asked the Plan to pay for the critical care services. You say that you are providing the supporting documentation requested. You request immediate payment for the care provided plus applicable late penalty fee as mandated by the state Prompt Pay law. The Plan denied your request. The Plan says information requested from the billing/rendering provider was not provided or not provided timely or was insufficient/incomplete.
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. In this case, medical records are needed to support the service provided. Medical records are still needed to support the service 93010. Records for the electrocardiogram was requested from the provider without success. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) central line placement (36556) electrocardiogram (93010) endotracheal intubation (31500) provided September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rezum procedure (53854).
You asked the Plan to pre-approve the Rezum procure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that for this procedure to be covered, there must be a maximum urinary flow rate of 15 mL/s. 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 the Rezum procure. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the record indicates that
the enrollee has benign prostatic hypertrophy with lower urinary tract symptoms. The record indicates that the maximum urinary flow rate is 32 ml/second. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Rezum procure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Rezum procedure (53854).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested services are 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 that you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 

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. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76642) provided on February 3, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you did not request this ultrasound and it should be covered by the Plan. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $100 copayment for outpatient diagnostic tests and therapeutic services and supplies including an ultrasound.
You have been asked to pay a $100 copayment for an ultrasound. The EOC confirms you pay $100 per day for an ultrasound. The record shows that the Medicare Allowed Amount for the service at issue is $97.12. This is lower than your required copayment responsibility of $100. An ultrasound 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 an ultrasound of the breast (76642) provided on February 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received October 6, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the hospital stated that the transfer to another hospital would be free. The Plan denied your request. The Plan says the correct cost share applied o the claim.
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 Ambulance Services. You have been asked to pay a $275 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0428, A0425) received October 6, 2020.