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

We decided that the Plan does not have to pay for the services (CPT 99000) provided to you on May 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee
Schedule indicates that payment for covered services are always bundled into payment for other services not
specified.
We looked at the file and Medicare rules. Procedure code 99000 is assigned a status indicator of "B" under the
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into
payment for other services. No separate payment can be made for CPT 99000. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan
does not have to pay for the services (CPT 99000) provided to you on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shingles vaccine received on August 31, 2020.You asked the Plan to pay forthe shingles vaccine. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine received on August 31, 2020.Benefits for the shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy services received June 15, 2020, through July 27, 2020
You asked the Plan to waive the copayments for physical therapy. You say that you should not be charged a copayment for physical therapy visits. The Plan denied your request. The Plan says the copayments were 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 $40 copayment for each Medicare-covered therapy visit. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you are being asked to pay is $440.00 ($40 x 11 visits = $440). Physical therapy falls within the Outpatient rehabilitation 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 copayments for physical therapy services received June 15, 2020, through July 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from September 11, 2020 and September 12, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that this claim should be reconsidered. The Plan denied your request. The Plan says the decision to admit a patient should be based on the severity of illness and intensity of services rendered.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from September 11, 2020 and September 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay foran additional unit of pulmonary perfusion imaging(CPT 78580) provided to the enrollee on August 14, 2020.You asked the Planto pay forthe scan. You say that this should be paid for.The Plandenied your request. The Plansaysthere is no additional documentation supporting an additional study which was billed and remains denied.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 78580 is "pulmonary perfusion imaging(eg, particulate)."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 the scan. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the records shows a single perfusion scan. CPT 78580 was done on 8/14/20, and was interpreted by the doctor under accession # N12303185VINHI.  There is no evidencea second perfusion lung scan was done the same date.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pay foran additional unit of pulmonary perfusion imaging (CPT 78580) provided to the enrollee on August 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten speech therapy visits.
You asked the Plan to pre-approve the additional ten speech therapy visits. The Plan denied your request. The
Plan says additional speech therapy visits are not reasonable or necessary as the enrollee has not made
significant improvement and does not appear to have the potential to improve.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional ten speech therapy visits.
Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not
generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior
therapy for this condition and it does not appear that the enrollee requires the unique skills of a professional
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed
only by a therapist, or under the supervision of a therapist.
There has been a review of the enrollee's plan of treatment and education on safe swallowing with staff.
The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 additional ten speech therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve an additional ten speech therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 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 referring provider 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. 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 medical services provided on July 8, 2020 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT Scan of the abdomen and pelvis (74178) provided on August 20, 2020.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this procedure was rendered in the appropriate place of service. The Plan denied your request. The Plan says the record indicates that this member was registered inpatient on the billed date of service but this claim was submitted with place of service code 22 for on campus-outpatient hospital.
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 74178 is not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service. The claim was not billed with the appropriate inpatient Place of Service code Based on this information, we decided that Medicare rules for coverage of the CT Scan have not been met. Therefore, we decided that the Plan does not have to pay for CT Scan of the abdomen and pelvis (74178) provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care treatment services provided from April 20,
2020, to April 27, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care treatment services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.
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 has network providers
available who can provide 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 wound care treatment services provided from
April 20, 2020, to April 27, 2020, by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the requested Proliais medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail an oral bisphosphonate drug, and zoledronic acid.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the review indicates that the enrollee is with osteoporosis. The Plan requires a trial of an oral bisphosphonate drug and Zoledronic Acid first before they will approve the requested drug.  In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Medicare Part B drugs provided on August 28, 2020.
You asked the Plan to waive the cost share for the services provided. You say that your copay is $40 per visit to a specialist. The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for chemotherapy drugs. You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare Part B prescription drugs 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 share for the Medicare Part B drugs provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the glycosylated hemoglobin test provided.

You asked the Plan to pay for the office visit and the glycosylated hemoglobin test. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services are to be billed to the primary insurer first.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the office visit and the glycosylated hemoglobin test until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for the office visit and the glycosylated hemoglobin test provided
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for hearing aids provided on
April 16, 2019.
You asked the Plan to reimburse you an additional amount for the hearing aids. The Plan denied your request.
The Plan says the hearing aids have been paid. The Plan paid $2,000 and the enrollee has a responsibility of
$200.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the hearing aids have been paid. The Plan paid
$2,000 and the enrollee has a responsibility of $200. Therefore, we decided that the Plan does not have to
reimburse you an additional amount for hearing aids provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye exam received on November 2, 2020.You asked the Plan to waive the copayment forthe services. You say that this should be paid for.The Plan denied your request. The Plan saysthe copayment was applied correctly according to your benefits and the services rendered.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 Medicare-covered eyeexams. You have been asked to pay a $35 copayment for the services. The services fall within the Medicare-covered eye exams 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 foran eye exam received on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93010) provided on June 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service would be included in the facility PPS payment.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 93010) provided on June 10,
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 from August 25, 2020, to September 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 from August 25, 2020, to September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on September 29, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that this bill does not reflect what the doctor said to you. 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 $250 copayment for outpatient surgery. You have been asked to pay a $250 copayment for an outpatient surgery. The correct copayment has been applied to the procedure that was provided. An outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided by a participating provider on September 29, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe services provided from December 4, 2019, to December 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that hospitals subject to OPPS report Condition Code G0 on FLs 24-30 (or the corresponding electronic location) when multiple medical visits occurred on the same day in the same revenue center but the visits were distinct and constituted independent visits. We looked at the file and Medicare rules. The visits at issue in this case were provided on different dates of service. This means that Condition Code G0 is not required in this case. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pay forthe services provided from December 4, 2019, to December 23, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.