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

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the abdomen (74183).

You asked the Plan to waive the copayment for the MRI. You say that you received a notice that many services had waived copayments due to the pandemic, and you believed the MRI would also have no copayment. The Plan denied your request. The Plan says some copayments were waived for your Plan. These include specialist visits, vision visits, lab tests, diagnostic tests (such as sleep studies, electrocardiograms, stress tests, etc.) and x-rays. An MRI is a diagnostic radiology service, which was not included in this waiver.

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 diagnostic radiology services.

You have been asked to pay a $250 copayment for the MRI. An MRI falls within the diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the abdomen (74183).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (CPT 99254) provided to the enrollee on July 9, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 99254 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 inpatient services (CPT 99254) provided to the enrollee on July 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for homemaker services provided from June 1, 2020, to August 31, 2020.
You asked the Plan to pay for the custodial care. You say that the services should be covered under continuity of care while in transition. The Plan denied your request. The Plan says homemaker services are not a covered Medicare benefit. The Plan also says that the services can be submitted for coverage under your Medicaid benefits.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Therefore, we decided that the Plan does not have to pay for homemaker services provided from June 1, 2020, to August 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Orencia.

You asked the Plan to pre-approve Orencia. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Orencia. Our reviewer says that the medication is medically necessary. Our physician reviewer found the documentation indicates that you have moderate to severe rheumatoid arthritis. You were previously on Orencia, but it was held due to osteomyelitis and surgery. The prescriber wishes to resume it at this point. The requested drug is medically necessary and reasonable for you. The requested drug has previously been effective for you and no safety issue is documented. The coverage elements for the requested drug are satisfied. Coverage of the requested drug is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have been met. Therefore, we decided that the Plan has to pre-approve Orencia.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CPT 85060) provided to the enrollee on October 23, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an inappropriate place of service for physician interpretation.
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 85060 is "blood smear, peripheral, with interpretation by physician." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider is an independent laboratory; therefore, it is inappropriate to bill CPT 85060. This service is considered a complete global service. We looked at this coder'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 Plan does not have to pay for laboratory services (CPT 85060) provided to the enrollee on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the eyeglasses provided on May 20, 2020.
You asked the Plan to pay for the eyeglasses. You say that you did not ask for a certain doctor. The Plan denied your request. The Plan says that the benefit limit has been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and the rules. In this case, claim information was not provided to show that the maximum benefit allowance has been met. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the eyeglasses provided on May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until October 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and provide additional reimbursement for the eye exam.

You asked the Plan to waive the copayment for the office visit and provide additional reimbursement for the eye exam. You say that these services should be paid for. The Plan denied your request. The Plan says you are responsible for these amounts.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for Medicare Covered Vision Services in a Specialist's office and that you pay any amount over $75 for a routine eye exam provided out-of-network.

You have been asked to pay a $25 copayment for the office visit. The office visit falls within the Medicare Covered Vision Services in a Specialist's office benefit category. This means that you have been asked to pay the correct amount for the office visit based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.

The file also shows that the Plan has approved the maximum benefit of $75 for the routine eye exam. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to waive the copayment for the office visit or provide additional reimbursement for the eye exam.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for additional reimbursement for eyewear received on October 14, 2020.
You asked the Plan to pay for the services. You say that you were only paid half of what was allowed. The Plan denied your request. The Plan says that this can only be partially reimbursed as the provider was out-of-network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with up to a $150 yearly allowance. We looked at the file and the Plan's rules. The plan has not substantiated their denial. There is no rule in the Evidence of Coverage saying that out-of-network vision care is only reimbursed at 50%. You are due the full reimbursement according to what the Evidence of Coverage states. Based on this information, we decided that the Plan's rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for additional reimbursement for eyewear received on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 30, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that you must receive care from in-network providers, with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services. 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 physician's services provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided to the enrollee by an out-of-network provider.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were not approved in advance.

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 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 office visit provided to the enrollee by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound (76642) provided on September 1, 2020.
You asked the Plan to waive the copayment for a breast ultrasound. You say that this should be considered part of your mammogram because it was a follow-up requested by your doctor. The Plan denied your request. The Plan says this service is separate from a screening mammogram and 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 $100 copayment for ultrasounds. You have been asked to pay a $93.53 copayment for a breast ultrasound because the allowed amount is less than $100. This service is not considered a part of a screening mammogram. 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 breast ultrasound (76642) provided on September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) for the enrollee.

You asked the Plan to pre-approve TTFT. You say that TTFT is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for TTFT. 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 TTFT. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found that TTFT is only approved for glioblastoma. The LCD does not provide coverage for anaplastic astrocytoma. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve tumor treatment field therapy (TTFT) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the enrollee may benefit from more therapy. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services.

You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. You say that you did not receive proper notice of this enrollee's benefit determination which is why the claim was submitted untimely. The Plan denied your request. The Plan says the corrected claim was not received until after the deadline to submit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the psychiatric diagnostic evaluation with medical services was not filed until August 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for eye services received on August 5, 2020.
You asked the Plan to reduce the copayment for the services. You say that this should have a copayment of $15. The Plan denied your request. The Plan says the 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 $45 copayment for outpatient visits for diagnosis of diseases/conditions of the eye. You have been asked to pay a $45 copayment for the services. The services fall within the outpatient visits for diagnosis of diseases/conditions of the eye 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 reduce the copayment for eye services received on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital follow-up visit (G0463) provided by an out of network (OON) provider.

You asked the Plan to pay for the follow-up visit. You say that this was a follow-up visit for an urgent service. The Plan denied your request. The Plan says they only cover out-of-network services in limited circumstances. The follow-up visit was not pre-approved or urgent.

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 hospital follow-up visit (G0463) provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare.

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 medical services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear.

You asked the Plan to pay for the eyewear. You say that this should be paid for. The Plan denied your request. The Plan says this claim processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyewear up to a $125 benefit.

We looked at the file and the Plan's rules. The plan paid $125 towards this claim. You are responsible for the remainder, which is $4.98. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for eyewear.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation visits.

You asked the Plan to waive the copayment for the services. You say that your issues were due to COVID. The Plan denied your request. The Plan says the copayments were assessed 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 $35 copayment for outpatient rehab services.

You have been asked to pay a $35 copayment for the services. The services fall within the outpatient rehab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient rehabilitation visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenously-administered multivitamins provided to the enrollee.

You asked the Plan to pre-approve the multivitamins. You say that this should be paid for. The Plan denied your request. The Plan says there are providers in the network who could have provided these services.

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 intravenously-administered multivitamins provided to the enrollee.