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

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided from September 21, 2019 to September 30, 2019.You asked the Plan to waive the copayment forthe SNF services. You say that you are being balanced bill and would like this reprocessed.The Plan denied your request. The Plan says that the appropriate cost share is being assessed.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 thePlan clearly says that you must pay a $100 copayment for per day for days 21-100. You have been asked to pay a $1000 copayment for the SNF services. The SNF services fall within the days 21-100 of skilled nursing facility services benefit category. Thismeans 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 forthe skilled nursing facility (SNF) services provided from September 21, 2019 to September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cardiac Magnetic Resonance Imaging (MRI) (75561) provided on November 15, 2019
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were out-of-network and not authorized or emergent.
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 Cardiac Magnetic Resonance Imaging (MRI) (75561) provided on November 15, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 7, 2019.
You asked the Plan to pay for the laboratory services. 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 laboratory services provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to theenrollee on July 17, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered to the enrollee on July 17, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on September 26, 2019.
You asked the Plan to pay for the outpatient hospital service. You say that you billed the enrollee's primary insurance. You say that you do not understand why Medicare is responsible for payment of the surgery. You also say that you do not know where the hospice guidelines can be found. The Plan denied your request. The Plan says the enrollee's Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the initial hospital care provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the joint injection provided on October 29, 2019.
You asked the Plan to waive the copayment for the joint injection. You say that this was not surgery and you say this is quite a lot of money for a shot. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $400 copayment for in-network Medicare-covered outpatient hospital surgery services. You have been asked to pay a $400 copayment for the joint injection. The joint injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the joint injection is considered a surgical procedure.
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 joint injection provided on October 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 26, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening
and disagree with 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 $250
copayment per visit for services provided in an ambulatory surgical center.
The record shows that you had a colonoscopy on September 26, 2019 due to a positive Cologuard test.
Therefore, the colonoscopy is considered diagnostic, not preventative, and you responsible to pay $100, which
is less than the $250 copayment.
You have been asked to pay $100 for a colonoscopy. A colonoscopy falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for a colonoscopy provided on September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on an implant removal (20680).
You asked the Plan to pay for surgical assistant services. You say that this was medically necessary. The Plan denied your request. The Plan says a surgical assistant was not necessary on these services.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 20680. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 surgical assistant services. Our reviewer says that the surgical assistant services at issue were not medically necessary. Our physician reviewer found this is a routine removal of hardware surgery from the leg. An assistant surgeon is not needed for this routine procedure. There is no justification in the records for the use of the assistant surgeon in this routine procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on an implant removal (20680).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit .
You asked the Plan to waive the copayment for an ER visit. You say that the ER would not perform an MRI, so you left and disagree with 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 ER visit
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on January 7, 2019 to February 20, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were in-network providers available to provide the services at issue.
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 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 the nursing facility care (99308) provided on January 7, 2019 to February 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forgenetic testing services provided to the enrollee on May 14, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere was no documentation indicating a need for genetic testing by the treating provider.The Planmust follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pay for the services. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found this test is not reasonable and there is no indication. There is no history of malignancy -there is simply a history of colonic polyps. The provider ordering the test is not a cancer or genetic specialist. This test is of unproven utility and there are no records supporting its useWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forgenetic testing services provided to the enrollee on May 14, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services on August 19, 2019.
You asked the Plan to pay for the lab services. You say that the codes are supported by the physician's custom profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.
We find that CPT codes 80307 and G0483 are not supported in the medical record. In this case, there is insufficient information to clearly show the intent that the tests be performed. 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 the lab services provided on August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran X-ray of the Spine (72050) provided on October 2, 2019.You asked the Plan to waive the deductible forthe X-ray. You say that you were told there would only be a $40 copayment.The Plan denied your request. The Plan says your plan deductible was not met at the time the services were rendered.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 Deductible for out-of-network services.The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-network Diagnostic Testing. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 Deductible for services rendered out-of-network. This cost sharing is a contractual obligation that had not been met at the time the X-ray was received on October 2, 2019.Therefore, we decided that the Plan does not have to waive the deductible foran X-ray of the Spine (72050) provided on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on July 25, 2019. You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says experimental and investigational services are not covered. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the test. Our reviewer says that the services
at issue in this case were not medically reasonable or necessary. Our physician reviewer found the documentation does not support that the Guardant360 genetic testing provided on 7/25/19 was medically reasonable and necessary for the enrollee in this case. The enrollee has metastatic gastric adenocarcinoma, and has been receiving palliative chemotherapy including trastuzumab. The documentation does not support that the repeat Guardant360 testing was likely impact the diagnosis and/or treatment of the enrollee's condition. 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 test have not been met. Therefore, we decided that the Plan does not have to
pay for the Guardant360 test provided to the enrollee on July 25, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the cervical spine provided on October 19, 2019.
You asked the Plan to pay for the CT of the cervical spine. You say that your provider is not paid by hospice and provided a service that is not related to hospice. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the cervical spine provided on October 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 18,
2019 to October 17, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
did not require any additional skilled services that could not have been provided in an alternate setting other
than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from September 18, 2019 to October 17,
2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe sales tax for dental services provided on October 17, 2019.You asked the Plan to pay forthe sales tax. You say that the claims department informed you that the Plan does not pay for the taxes. You also say that you were never informed about taxes not being covered when you signed up for this plan.The Plan denied your request. The Plan says that they consider payment for this service to be part of the payment for the other services and it is not paid separately.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. There is no notice is the EOC that sales taxes associated with the dental services would not be covered by the Plan.In this case, the Plan contract does not say that sales tax would not be covered and says that payment will be made up to the $1,500 dental allowance for dental care.Therefore, we decided that the Plan has to pay forthe sales tax for dental services provided onOctober 17, 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 to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 31, 2019.
You asked the Plan to pay for the orthoses. 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 knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 31, 2019.