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

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 28, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on September 4,
2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or
hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we
decided that the Plan does not have to pay for the durable medical equipment provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye exam (92014) and fundus photography
(92250) provided on July 15, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the medical eye exam and fundus photography. You say that the enrollee was
unaware the provider they saw was OON. The Plan denied your request. The Plan says the provider is not a
network provider and that authorization was not obtained in advance; therefore, the claim has denied correctly.
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 medical eye exam (92014) and fundus
photography (92250) provided on July 15, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a laboratory test and an X-ray provided on
August 7, 2020.
You asked the Plan to waive the copayments for a laboratory test and an X-ray. You say that you were told that
all copayments were waived due to COVID-19. 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 $10
copayment for lab services and an X-ray.
You received a laboratory test on August 7, 2020. Therefore, you are responsible to pay the $10 copayment.
You received an X-ray on August 7, 2020. Therefore, you are responsible to pay the $10 copayment.
The total amount you owe is: $20.
You have been asked to pay the total copayment amount of $20 for a laboratory test and an X-ray. A laboratory
test and an X-ray 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 copayments for a laboratory test and an X-ray provided on
August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ongoing referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says medically necessary care is available 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an ongoing referral to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee's current needs cannot safely be met at a lower level of care.The Plan denied your request. The Plan says the enrollee's rehab needs are not complex enough to require coordinated care between therapy disciplines.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 hospital for surgical repair of a humerus fracture after a fall. His medical conditions are stable. The complexity of hisnursing, medical and rehabilitation needs donot require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on March 16, 2020 billed with code 66180. You asked the Plan to pay for the outpatient hospital care. You say that all coding for this service is correct, and the claim should be paid in full. The Plan denied your request. The Plan says the claim includes a device-intensive procedure code but no corresponding device code. This claim must be corrected to be paid. The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims which report a device-intensive procedure code must also include at least one device code. The code 66180 is assigned device-intensive status in the OCE. Review of the claim shows that no device codes were reported. This claim was correctly denied requiring correction. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on March 16, 2020 billed with code 66180.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe copayment paid for the office visit and EKG provided on July 20, 2020.You asked the Plan to reimburse you forthe copayment paid for the office visit and EKG. You say that you should not have had a separate copayment for the EKG.The Plan denied your request. The Plan says you were only charged one copayment for the office visit and EKG.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 $15 copayment for outpatient diagnostic test at a specialist office. You have been asked to pay one$15 copayment for the copayment paid for the office visit and EKG. Although the copayment was applied to the EKG there is only one copayment for this date of service. The copayment paid for the office visit and EKG falls within the outpatient diagnostic test at a specialist office 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 reimburse you forthe copayment paid for the office visit and EKG provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80307, G0483) provided on April 3, 2020.
You asked the Plan to pay for laboratory services. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that although this was billed with POS 81 for an independent laboratory, the specimen was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (80307, G0483) provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on June 9 to July 14, 2020, by your psychiatrist.
You asked the Plan to pay for psychotherapy. You say that you had received a letter approving your request for services from the provider. The Plan denied your request. The Plan says the provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on June 9 to July 14, 2020, by your psychiatrist.
Your complaint about the Plan reversing its approval without adequate notice 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided from March 6,
2020, to June 8, 2020.
You asked the Plan to pay for the home infusion services. You say that the service was medically necessary.
The Plan denied your request. The Plan says the CPT code is not a valid CPT code.
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 S9328 is not supported in the medical record. Specifically, this code is marked with a
status indicator of "I" and is not valid for Medicare purposes. Based on this information, we decided that
Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the
Plan does not have to pay for home infusion services (S9328) provided from March 6, 2020, to June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on May 22, 2020.
You asked the Plan to waive the coinsurance for DME. You say that the enrollee was disoriented while being
fitted for the device and could not consent. The Plan denied your request. The Plan says the claims were
processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for items with a total rental or purchase price of $50.01 or more for DME and
related supplies.
The medical records show that the enrollee received DME on May 22, 2020. The allowed amount is $1,162.75
and 20% of that is $232.55.
The enrollee has been asked to pay the total coinsurance amount of $232.55 for DME. DME falls within the
DME and related supplies benefit category. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for
DME provided on May 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior resin-based composite of one surface and anterior resin-based composite of four or more surfaces involving incisal angle provided on August 12, 2020 by an OON provider.
You asked the Plan to pay for the resin-based composites. You say that you believe these services should be covered as a restoration, and not a filling due to decay. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that your resin-based composite benefits have been satisfied and the frequency limitation had been exceeded.
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, you are responsible for a 50% coinsurance when the resin-based composite is received OON. The contract also says that resin-based composites are limited to one procedure per calendar year. The record shows that you received two resin-based composites on August 12, 2020, one of which was covered at the OON rate by the Plan, and your resin-based composite benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the anterior resin-based composite of one surface and anterior resin-based composite of four or more surfaces involving incisal angle provided on August 12, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lesion removal provided on June 17, 2020.
You asked the Plan to waive the copayment for the lesion removal. You say that you received a bill from the dermatologist. 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 $40 copayment for each specialist visit. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department or any other location. You have been asked to pay a $40 copayment for the lesion removal. Lesion removal 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 lesion removal provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea custom fabricated ankle/foot orthosis (L1940) and addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820) for the enrollee.You asked the Plan to pre-approvethese services. You say that the member suffers from profound neuropathic diabetes, hammertoe deformities and is having a great deal of instability putting him at risk for significant falls.The Plan denied your request. The Plan says that the notes do not show results of specific foot/ankle instability maneuvers to confirm the presence of instability and do not provide justification for the need to control the ankle or foot in more than one plane.The Plan follows Medicare rules. Medicare rules say that ankle/foot orthoses are covered if the the above criteria have been met.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 these services. Our reviewer says that these services are not medically reasonable and necessary for the enrollee in this case. Podiatrist office notes do not reveal objective measures of range of motion, strength and laxity in different planes of motion in ankle, foot and digits. The notes do not include a detailed objective neuromuscular exam or gait evaluation or foot/ankle instability maneuvers. There is no objective evidence of instability on a physical exam or evidence of the need to control the ankle or foot in more than one plane. The documentation does not support that this patient requires custom fabricated braces versus prefabricated braces that support the patient needs the requested orthosis for stabilization for medical reasons and to benefit functionally. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea custom fabricated ankle/foot orthosis (L1940) and addition to lower extremity orthosis, soft interface for molded plastic, below knee section (L2820) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) services rendered on June 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) services rendered on June 3, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a thorax Computed Tomography (CT) and an abdomen/pelvis CT.
You asked the Plan to pre-approve CT, thorax; without contrast material (71250) and CT, abdomen and pelvis;
without contrast material in one or both body regions, followed by contrast material(s) and further sections in
one or both body regions (74148). You say that you would like to complete five years of surveillance imaging.
The Plan denied your request. The Plan says that the enrollee is clinically well without concerns for recurrence
of carcinoma.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 Computed tomography, thorax; without
contrast material (71250) and Computed tomography, abdomen and pelvis; without contrast material in one or
both body regions, followed by contrast material(s) and further sections in one or both body regions (74148).
Our reviewer says that the service is medically reasonable and necessary. Our physician reviewer found
standard of care, applicable to the enrollee's circumstance of breast cancer surveillance, warrants CT chest w
contrast (CPT 71260) + CT abdomen/pelvis with contrast (CPT 74177) every three months to assess
measurable metastatic disease for patients on either maintenance therapy or being monitored off therapy. While
it cannot be determined from the enrollee's available record that metastatic disease has been definitively found,
prudence based on presented evidence medically justifies the studies above in the enrollee's case.
Relative to the above studies for surveillance after transplant for HCC, insufficient information was provided to
calculate Appellant's RETREAT score. However evidence has been presented in the available record to support
suspicion of recurrent tumor, for which at minimum a CT abdomen (CPT 74160) is medically appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Computed tomography, thorax; without contrast material (71250) and
Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed
by contrast material(s) and further sections in one or both body regions (74148) have been met. Therefore, we
decided that the Plan has to pre-approve a thorax Computed Tomography (CT) and an abdomen/pelvis CT.
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 to open the case again, we will
send you a letter.