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

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
August 9, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided.

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 an in-network office visit with a specialist. 

You have been asked to pay a $35 copayment for the in-network specialist office visit provided. 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 office visit (99214) provided on August 9, 
2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for GeneSight Psychotropic testing (CPT code(s): 81225, 81226, 81227, 81230, and 81381) provided to the enrollee on June 21, 2021.

You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says that the evidence does not show that this test has value in helping the enrollee's physician choose what medication to give the enrollee, or how much medication to give the enrollee.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has depression and anxiety that is refractory to multiple trial and failure of multiple medicines, outpatient and inpatient treatments. The enrollee's provider ordered the GeneSight Psychotropic test to research if there is a genetic abnormality. The review has determined that the items/services at issue in this case are medically reasonable and necessary. 

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 services have been met. Therefore, we decided that the Plan has to pay for GeneSight Psychotropic testing (CPT code(s): 81225, 81226, 81227, 81230, and 81381) provided to the enrollee on June 21, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and eyeglasses provided on August 28, 2021.
You asked the Plan to pay for the eye exam and eyeglasses. You say that you were not aware there were participating and non-participating providers. You say that you were never advised you didn't have coverage for out-of-network providers. The Plan denied your request. The Plan says you must use network providers to get your medical care and services.
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 when they are received from a participating provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Specifically, the services were not received from a participating provider. Therefore, we decided that the Plan does not have to pay for the eye exam and eyeglasses provided on August 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from 
November 6, 2020, through December 5, 2020.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF care 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 from a nursing 
perspective, the enrollee received oral medications. The enrollee had stable vital signs. She tested positive for 
Coronavirus (COVID-19) and was placed on precautions. Regarding rehabilitation services, the enrollee 
received physical therapy (PT) and occupational therapy (OT). By the dates in question, the enrollee was at a 
supervision to contact guard assist level for functional mobility including gait to 150 feet with a rolling 
walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled 
nursing service needs. There are no identifiable skilled therapy service needs. The enrollee did not require 
skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 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 November 6, 2020, through 
December 5, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 21, 2021, to July 23, 2021.
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee was appropriate for inpatient admission due to medically necessary hospitalization spanning two midnights. The Plan denied your request. The Plan says that the information provided does not show that the enrollee had a stroke, infection in the blood (bacteremia), infection within the kidney (pyelonephritis), fever, or blockage of urine flow. The Plan also says that the enrollee did not require an infusion of a medicine to raise their blood pressure.
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 the 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 based on the age of the patient, ongoing sepsis and complexity of the case, it was expected at the time of admission that the patient would require hospital services that would likely cross 2 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 the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 21, 2021, to July 23, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acupuncture (97810, 97811) provided on September 7, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $30 copayment for acupuncture provided by a qualified specialist. 

You have been asked to pay a $30 copayment for the acupuncture provided by a qualified specialist. The provider in this case is a licensed acupuncturist.

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 acupuncture (97810, 97811) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) Cervical or vaginal cancer screening (G0101) screening papanicolaou smear (Q0091) provided August 19, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the numbers do not match to the billing, adjustment or application to your deductible. The Plan denied your request. The Plan says the claim was processed and applied to the deductible per the Evidence of Coverage

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 $750 deductible and 40% out of network coinsurance rendered in a PCP or specialist's office which applies to Cervical and vaginal cancer screening. 

The item or service you asked the Plan to pay for falls within the benefit category Cervical and vaginal cancer screening.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to Cervical and vaginal cancer screening. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on August 19, 2021. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) Cervical or vaginal cancer screening (G0101) screening papanicolaou smear (Q0091) provided August 19, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014), the eye refraction (92015), the scanning computerized ophthalmic diagnostic imaging (92134), and the sensorimotor examination with multiple measurements of ocular deviation (92060) rendered by an out-of-network (OON) provider on June 21, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered 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.

You are 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 ophthalmological medical examination and evaluation (92014), the eye refraction (92015), the scanning computerized ophthalmic diagnostic imaging (92134), and the sensorimotor examination with multiple measurements of ocular deviation (92060) rendered by an out-of-network (OON) provider on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the therapeutic radiology rendered on July 26, 2021.

You asked the Plan to waive the coinsurance for these services. You say that the coinsurance was applied correctly. The Plan denied your request. The Plan says you were not aware that the provider was out-of-network.

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 20% coinsurance for Medicare-covered therapeutic radiology services.

Review of the file shows that you received therapeutic radiology services from an out-of-network provider on July 12, 2021. Although the provider was out-of-network, the Plan agreed to process the claims with your in-network benefits.

You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered therapeutic 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 coinsurance for the therapeutic radiology rendered on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on July 29, 2021.

You asked the Plan to pay for the shingles vaccine under Medicare Part B. You say that your physician stated the shingles vaccine was necessary. The Plan denied your request. The Plan says coverage for the shingles vaccine must be submitted to your Medicare Part D carrier.

The Plan is correct in this case. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. This vaccine was preventative in nature. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on July 29, 2021 under your Medicare Part B benefit. Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 13, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you did not know that by changing dental offices, you would not be eligible for another exam. The Plan denied your request. The Plan says you are covered for oral evaluations once, every 6 months.
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. The Plan covers a limited oral evaluation once, every 6 months. We looked at the file and Medicare rules. The records show that you had a limited oral evaluation on July 23, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 13, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for assistance with activities of daily living and personal care (99509) provided from April 1, 2021, to April 30, 2021.

You asked the Plan to pay for the home visits. You say that this claim should not have been denied because these services were medically necessary. The Plan denied your request. The Plan says this request is not medically necessary because the records show you do not have a skilled need. The Plan also says that this request is not covered by the Plan.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the home visits for assistance with activities of daily living and personal care (99509) provided from April 1, 2021, to April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) prophylaxis
(D1110) and bitewing x-rays (D0274) provided on July 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for dental services. You say that you were told the provider was in-network prior to
your appointment. The Plan denied your request. The Plan says you must obtain covered services, except for
emergency care and out-of-area urgent care, from Plan providers.
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. The Plan covers dental
services when the services are obtained by a participating Plan provider.
We looked at the file and Medicare rules. Specifically, the services were rendered by an OON provider. Based
on this information, we decided that the Plan's rules for coverage of dental services have not been met.
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150)
prophylaxis (D1110) and bitewing x-rays (D0274) provided on July 29, 2021, by an out-of-network (OON)
provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for optical coherence tomography (92134) ophthalmic ultrasound, diagnostic; B-scan (76512) provided June 15, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you are asking for coverage of your medical bills as your financial situation does not allow you to do so. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $50 copay for each Medicare covered outpatient diagnostic procedure and test in an office setting or imaging center.

You have been asked to pay $50 copay for the diagnostic service. The diagnostic service 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 waive the copayment for optical coherence tomography (92134) ophthalmic ultrasound, diagnostic; B-scan (76512) provided June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray and panoramic x-ray
provided on August 11, 2021.
You asked the Plan to pay for the intraoral complete series x-ray and panoramic x-ray. You say that you did
request the complete series x-ray. You say that the office did not request any payment and you were told the
services were covered. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
intraoral complete series x-ray and panoramic x-ray provided on August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 26, 2021 to September 29, 2021.

You asked the Plan to pay for SNF care. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, can be provided at a lower level of care. 

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 pay for skilled nursing facility (SNF) care provided from September 26, 2021 to September 29, 2021.