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

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided from May 3, 2021, through May 13, 2021.
You asked the Plan to waive the copayment for outpatient hospital services. The Plan denied your request. The Plan says you have been asked to pay 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 $275 copayment for outpatient hospital services. You have been asked to pay a $275 copayment for the outpatient hospital services received on May 3, 2021, and May 13, 2021. You have also been asked to pay the allowed amount of $49.99 for the outpatient hospital services received on May 10, 2021, which is less than the $275 copayment. Outpatient hospital services 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 for outpatient hospital services provided from May 3, 2021, through May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotropic test provided on October 15, 2020.
You asked the Plan to pay for the psychotropic test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The psychotropic test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the psychotropic test provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 25, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99336) provided
on April 14, 2021, by an OON provider.

You asked the Plan to pay for the established patient assisted living visit. You say that you would like this
claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was
not obtained for these services rendered by an OON provider.

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 established patient assisted living visit (99336)
provided on April 14, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.

You asked the Plan to reimburse you for a health club membership. You say that you should be reimbursed because it is included in your policy every year. The Plan denied your request. The Plan says your reimbursement request for the 2020 benefit year was received after the March 31st deadline.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility. Reimbursement requests must be received by the Plan no later than March 31st of the following year.

The Plan's rules for coverage of gym benefits have not been met. The records show that you submitted a reimbursement request for your 2020 benefit year on May 10, 2021. The EOC confirms that reimbursement requests must be received by the Plan no later than March 31st of the following year. Therefore, we decided that the Plan does not have to reimburse you for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for colectomy (44160-XS) provided on April 15, 2021.

You asked the Plan to pay for 44160-XS. You say that this claim is coded correctly per Medicare coding guidelines and you have submitted medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support that 44160 was performed to a separate organ/structure unrelated to the primary procedure.

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 44160 is colectomy, partial, with removal of terminal ileum with ileocolostomy. 

We asked our coder 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 44160-XS. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the documentation does not support that 44160 was performed to a separate organ/structure unrelated to the primary procedure. Consequently, modifier -XS is not supported. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 44160-XS have not been met. Therefore, we decided that the Plan does not have to pay for colectomy (44160-XS) provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on April 21, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient hospital admission. You say that the medical records provided support the request for an inpatient admission. The Plan denied your request. The Plan says there is no documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay.
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 pre-approve an inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission have been met in this case.
Our physician reviewer found the enrollee is a 76-year-old female who is undergoing an elective left shoulder joint revision of a total shoulder arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under common procedural terminology (CPT) code 23472 and is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. There is no evidence that the admitting physician reasonably expects that the enrollee's necessary hospital 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 an inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a scapular fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April
29, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not believe that
you received services from a nutritionist. The Plan denied your request. The Plan says the copayment applied
was correct.
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 specialist visit for Medicare-covered services.
You have been asked to pay $41.53 for a specialist office visit, which is less than your $50 copayment.
Specialist office visits fall within the 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 for a specialist office visit provided on April 29,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on January 20, 2021.

You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary and billed correctly. The Plan denied your request. The Plan says the report POS code is not supported.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 

We looked at the file and Medicare rules. The documentation does not support that this sample was taken directly by the lab. As such, POS code 81 is not appropriate. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray interpretation provided on May 27, 2021 by
an out-of-network provider.
You asked the Plan to pay for the radiologic examination, chest; single view (71045) interpretation. You say
that you are unable to get authorizations for these patients. The Plan denied your request. The Plan says you did
not request prior authorization as required.
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 service 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 the service. Therefore, we decided that
the Plan does not have to pay for the chest x-ray interpretation provided on May 27, 2021 by an out-of-network
provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental cleaning (D1110) and periodic oral exam (D0120) provided
on June 21, 2021.
You asked the Plan to pay for the dental services. You say that you knew this provider was out-of-network and
you expected to pay more than you would at an in-network provider, but you do not understand why you are
not being reimbursed anything at all for these services. You say you have not had these services within the last
6 months. The Plan denied your request. The Plan says that this provider has chosen to opt-out of Medicare,
and therefore no payment can be made.
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 one periodic
oral evaluation (D0120) and one dental cleaning (D1110) every 6 months. Services can be received from a
provider that is out-of-network, but you may pay more for the services.
The plan offers coverage for the services at issue; however, they were denied by the Plan in this case because
they were received from a provider who has chosen to opt-out of Original Medicare. Normally, providers who
have opted-out of Medicare are unable to receive payments from Medicare plans for medical services.
However, the Centers for Medicare and Medicaid Services (CMS) has stated that opt-out provisions do not
apply to supplemental benefits unless the Plan specifically states this limitation in the contract. Dental services
are not covered by Medicare and are instead covered by a supplemental benefit offered by the Plan. Opt-out
rules do not prevent a provider from being paid for non-Medicare covered benefits. The Plan cited a section of
their contract in their argument, but this information was pulled from a section titled, "Basic rules for getting
your medical care covered by the plan." Dental care is not considered medical by Medicare rules.
We looked at the file and Medicare rules. The contract states that one periodic oral evaluation and one dental
cleaning can be covered every six months. The contract also states that out-of-network dental care is covered.
Based on this information, we decided that the Plan's rules for coverage of the dental services have been met.
Therefore, we decided that the Plan has to pay for the dental cleaning (D1110) and periodic oral exam (D0120)
provided 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to be in this rehabilitation center because you have been having problems with really low blood pressure levels in the last two (2) weeks. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and hypotension. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for repairs to custom CROW boot orthosis (L3020, L3360, and L3410,) on April 14, 2021.
You asked the Plan to pay for the foot orthosis. You say that the provider said that these would be covered. The Plan denied your request. The Plan says orthopedic footwear are not covered.
The Plan must follow Medicare rules. Medicare rules say that [orthopedic footwear are covered for select beneficiaries with diabetes for prevention or treatment of diabetic foot ulcers or if they are an integral part of a covered brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for your condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the foot orthosis have not been met. Therefore, we decided that the Plan does not have to pay for repairs to custom CROW boot orthosis (L3020, L3360, and L3410,) on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on September 18,
2019, through May 29, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because
these tests were rendered in good faith and ordered by the member's treating physician. The Plan denied your
request. The Plan says it has been determined that these are fraudulent claims.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services in the medical record, is required for Medicare-covered laboratory services.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Specifically, the documentation does not include any
clinical information to verify that the member's treating physician ordered this testing or why this testing was
ordered. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482)
provided on September 18, 2019, through May 29, 2020.