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

We decided that the Plan does not have to pay for oral function therapy services provided on January 2, 2020.
You asked the Plan to pay for the services provided. You say that many of the requested services are not
available on an outpatient basis due to the pandemic. The Plan denied your request. The Plan says there is
insufficient documentation to corroborate the services.
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 92526 is treatment of swallowing dysfunction and/or oral
function for feeding.
We looked at the file and the rules. The claim provided indicates the services at issue were provided in a home
setting. Procedures must be reported with the most comprehensive CPT code that describes the services
performed. There is a more appropriate code for the services provided in the home setting. Based on this
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the
Plan does not have to pay for oral function therapy services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a Watchman device.

You asked the Plan to provide coverage for a Watchman device. You say that this device is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated QIC did not apply the correct coverage criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for the Watchman device. The QIC Physician Reviewer determined that the requested Watchman device was medically reasonable and necessary. The Plan requested a reopen and stated that the reviewer did not consider that the documentation did not meet the required Medicare criteria. Our Medical Director has concluded that based on the medical records, the Plan is correct in this case. The documentation does not support that the coverage criteria as established by NCD 20.34 were met in this case. Specifically, the case file does not contain documentation of formal shared decision-making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with non-valvular atrial fibrillation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Watchman device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Watchman device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the
enrollee on October 13, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist
orthosis (L3960) provided to the enrollee on October 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy, 60 minutes (90837) provided on March 11, 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 the individual psychotherapy, 60 minutes (90837) provided on March 11, 2020 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 July 15, 2020, to July 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 July 15, 2020, to July 22, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from October 24, 2020, through November 22, 2020

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continued stay at the SNF is 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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment from October 24, 2020 to November 22, 2020. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment from October 24, 2020 to November 22, 2020. Daily skilled services were not required from October 24, 2020 to November 22, 2020.

As a practical matter, the enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from October 24, 2020 to November 22, 2020. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from October 24, 2020, through November 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a custom mouth guard (D9945) received on October 19, 2020.

You asked the Plan to pay for a custom mouth guard. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a custom mouth guard (D9945) received on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on November 20, 2020.
You asked the Plan to pay for the testing services. You say that your physician could not proceed with chemotherapy until you had the procedure done. The Plan denied your request. The Plan says the testing did not meet Medicare criteria.
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 did not pre-approve the services at issue. The testing services are also not FDA approved. 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 genetic testing services provided on November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for transfer bench (E0248) provided on November 25, 2020, by
an OON provider.
You asked the Plan to pay for transfer bench. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says prior authorization was not obtained for this service.
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 transfer bench (E0248) provided on November 25,
2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80053, 80061, 84443, 85025, G0463) provided on November 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that these services should be covered. The Plan denied your request. The Plan says these 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 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 laboratory services (36415, 80053, 80061, 84443, 85025, G0463) provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 22, 2020, to April 1, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were being treated for suspected COVID-19 and feel that you should not be responsible for 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 $310 copayment for days 1-5 for inpatient hospital care. 

You had an inpatient hospital stay from March 22, 2020, to April 1, 2020. Therefore, you are responsible to pay a $310 copayment for days 1-5 (March 22, 2020, to March 26, 2020). $310 (copayment) x 5 (inpatient days) = $1,550. 

You have been asked to pay the total copayment amount of $1,550 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from March 22, 2020, to April 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy, 60 minutes (90837) provided on February 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the services 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, 60 minutes (90837) provided on February 18, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery (66984, V2787) provided on October 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON cataract surgery. You say that you believed the provider had approval for these services. The Plan denied your request. The Plan says these 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 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 cataract surgery (66984, V2787) provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on June 11, 2020.

You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 services at issue in this appeal. The Plan did not pre-approve the service 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 nursing facility care (99309) provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99307, 11042) provided on December 28, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed on a duplicate claim line.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 99307 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of CPT code 99307 have not been met. 

Medicare rules also say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

In this case, CPT 11042 was billed on a duplicate claim line to one previously processed and paid by the Plan. Duplicate claims and claim lines are not payable. Therefore, we decided that the Plan does not have to pay for the services (99307, 11042) provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery, co-payment for physician services, and coinsurance for an injection, and an outpatient surgery provided by participating providers on June 25, 2019, to August 10, 2020.

You asked the Plan to waive the deductible for an outpatient surgery, co-payment for physician services, and coinsurance for an injection, and an outpatient surgery. You say that you pay for insurance, so you do not know why you had to pay so much money out-of-pocket. The Plan denied your request. The Plan says the correct charges have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 deductible, a $25 co-payment for practitioner/physician services/in-network/specialist, a 10% coinsurance for Medicare Part B prescription drugs/in-network and outpatient surgery/in-network.

You have been asked to pay a $245 deductible, a $25 co payment for physician services and a 10% coinsurance for an injection and an outpatient surgery.

Total Amount Being Asked to Pay: $710.06

Physician services falls within the practitioner/physician services/in-network/specialist benefit category. An injection falls within Medicare Part B prescription drugs/in-network benefit category. An outpatient surgery falls within outpatient surgery/in-network 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 deductible for an outpatient surgery, co-payment for physician services, and coinsurance for an injection, and an outpatient surgery provided by participating providers on June 25, 2019, to August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on December 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 subsequent nursing facility care services provided on December 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
December 21, 2020.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the eyewear benefit only covers up to the maximum allowed amount of a $150 eyewear allowance.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a $150 allowance once every 24 months toward the purchase price of eyewear. We looked at the file and the Plan's rules. The file shows that the Plan paid the claim correctly with a $150 eyewear allowance. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 21, 2020.