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

We decided that the Plan does not have to pay forthe device evaluation (93280) provided on July 30, 2019 by an out of network (OON) provider.You asked the Plan to pay fora device evaluation. You say that this service should be covered.The Plan denied your request. The Plan says this service was not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has networkproviders 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 forthe device evaluation (93280) provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from November 19, 2019 through November 21, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from November 19, 2019 through November 21, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 20, 2019.You asked the Plan to pay forthe ambulance services. You say that after treatment you declined to be taken to the hospital.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 20, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on July 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on August 15, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you cannot afford to pay the copayment.The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.The rules say a plan must disclose to itsenrollees 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 $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 forthe ambulance transport provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forpulse oximetry provided on August 26, 2019.You asked the Plan to waive the coinsurance forpulse oximetry. You say that you disagree with the unexpected 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 20% coinsurance for non-radiological diagnostic services.You received pulse oximetry on August 26, 2019. The allowed amount is $26.18 and 20% of that is $5.24. You have been asked to pay the total coinsurance amount of $5.24 for pulse oximetry. Pulse oximetry falls 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 waivethe coinsurance forpulse oximetry provided on August 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Chest X-ray (71045) provided October 17, 2019. You asked the Plan to pay forthe x-ray. You say that services were medically necessary and billed correctly.The Plan denied your request. The Plan says the claim did not include the correct modifiers.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 71045 is not supported in the medical record. Specifically, the service at issue was provided at a Skilled NursingFacility. The claim submitted did not include a 26 modifier to denote that this procedure was part of a Part A inpatient stay. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora Chest X-ray (71045) provided October 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on November 4, 2019.You asked the Plan to waive the copay forthe ambulance transport. The Plan denied your request. The Plan says that the cost sharing applies to each one-way trip.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 $225 copay for each one-way Medicare-covered ground transportation service. You have been asked to pay a $225 copay for the ambulance transport. the ambulance transport falls within the one-way Medicare-covered ground transportation service 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 copay forthe ambulance transport provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on December 4, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be charged a copayment. 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit.The specialist office visit falls within the per specialist visit "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 forthe specialist office visit provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 23, 2019.You asked the Plan to pay for the laboratory services. The Plan denied yourrequest. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has beendocumented.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 thelaboratory 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 laboratory services provided on June 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided on August 11, 2019.You asked the Plan to pay forthe ambulance service. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the claim was submitted with a modifier that defines the transport is not coverable by Medicare and prevents payment.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 provider submitted their claim for payment with a GY modifier that indicates that the services provided were non-emergent.  Because the provider is out of network, the plan cannot over-ride the claim. Non-emergent ambulance transport is not a covered service.Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulanceservice provided by on August 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye exam (92004) and the fundus photography (92250) provided by the out of network (OON) on October 22, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment as the member was in an assisted living facility at the time the services were rendered and he could not choose an in-network optometrist as they do not provide services in the member's place of residence.Additionally, you say that your company has an exclusive contract with the facility and your doctors are the only providers who will treat the patients for optometry care. The Plan denied your request. The Plan says the services were provided by an out of network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe eye exam (92004) and the fundus photography (92250) provided by the out of network (OON) provider on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient clinic visits provided on August 14, 2019 and November 11, 2019.You asked the Plan to waive the copayment forthe outpatient clinic visits . You say that you did not receive chemotherapy like the claim states.The Plan denied your request. The Plan says the copayments 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 $50 copayment for each in-network outpatient clinic visit. You have been asked to pay $22.93, which is less than the standard $50 copayment for each outpatient clinic visit.The total amount you owe is $45.86 ($22.93/visit x 2 visits = $45.86). The outpatient clinic visits fall within the "Outpatient hospital 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 forthe outpatient clinic visits provided on August 14, 2019 and November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction rendered to you on December 4, 2019.You asked the Plan to pay forthese services. You say that you needed the services for special corrective lenses.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay forthe eye refraction rendered to you onDecember 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0652).You asked the Plan to pay fora pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires. The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forscreening testing provided on November 29, 2019.You asked the Plan to pay forscreening test. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not a covered benefit for the diagnoses listed and was performed forscreening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, screening test, was requested solely for screeningpurposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forscreening testing provided on November 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on October 23, 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 the services are not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 87801, 87641, 87640, 87651, 87653, 87471, 87481, and 87551. Codes 87641, 87640, 87651, 87653, 87471, 87481, and 87551 are column II codes with a modifier indicator of 1 when billed with column I code 87801. Codes 87641, 87640, 87651, 87653, 87471, 87481, and 87551 were not billed with an appropriate modifier toallow for separate payment. The -59 modifier is not appropriate, as the services were not separate and distinct procedural services.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on October23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health care supervision rendered to the enrollee on September 30, 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 procedure code G0181 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes G0181 and 99495. Code G0181 is a column II codewith a modifier indicator of 1 when billed with column I code 99495. Code G0181 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe home health care supervision rendered to the enrollee on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Planhasto pre-approveCT scan of the abdomen, pelvis, and thorax for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary to monitor for any new findings.The Plandenied your request. The Plansaysthatthis is not indicated for surveillance for this type of cancer.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 the scan. Our reviewer says that the requested scan is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of bilateral lung cancer and importantly has had intra abdominal metastasis to the left adrenal gland, resected in 2018. It is certainly reasonable to assess the abdomen and pelvis for metastatic disease particularly in view of the prior metastasis to the adrenal gland. The other valid indicationis the history of hemachromatosis. Together, the history is certainly a valid indication for the requested CT of the abdomen and pelvis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the abdomen, pelvis, and thorax for the enrollee.If the Plandoes 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/orsend us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on September 6, 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 the services are not covered.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 Medicareprogram 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 forthe laboratory services rendered to the enrollee on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided May 24, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that this is the patient's primary care physician; therefore, no prior authorization should be required.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say thatplans 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 wouldrequire the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit provided May 24, 2019 by an out of network (OON) provider.