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

We decided that the Plan does not have to pay for the skilled nursing services provided from May 13, 2021, to May 31, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 13, 2021, to May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction testing provided on May 6, 2021.
You asked the Plan to pay for the refraction. You say that this was done in order to provide the eyeglasses you needed after cataract surgery. You feel that this should be paid. The Plan denied your request. The Plan says refraction services are not covered by Medicare, even if done for an otherwise covered condition. You have also used up your routine eye exam benefit through the exam provided on March 29, 2021.
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 a routine eye exam only once every 12 months. We looked at the file and the Plan's rules. The file shows that you received a routine eye exam on March 29, 2021. In addition, this service cannot be covered by Original Medicare. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction testing provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an optometrist on May 24, 2021.
You asked the Plan to waive the copayment for the optometry visit. You say that you do not feel you should have to pay this copayment because the visit only took two minutes and you feel as though the doctor was unprofessional. The Plan denied your request. The Plan says you were charged this copayment 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 visits with a specialist. You have been asked to pay a $35 copayment for the optometry visit. The optometry visit falls within the visits with a specialist benefit category. This copayment applies regardless of your satisfaction with the services. 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 you had with an optometrist on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drug (Eligard) you received on May 11, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drug. You say that you did not have these services. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says as of this date of service, you had only met $5451.49 of your $6700 out-of-pocket maximum.
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 Medicare Part B and chemotherapy drugs. You have been asked to pay 20% coinsurance for the chemotherapy drug. The billing records show that you received 45MG of Eligard, which is a chemotherapeutic drug. 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 chemotherapy drug (Eligard) you received on May 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 3, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you declined being transported to the hospital since there did not seem to be any reason to make an unnecessary hospital visit. The Plan denied your request. The Plan says since you were not transported by the ambulance, the service is not covered under your plan.
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 April 3, 2021. 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 for ambulance response and treatment, no transport (A0998) provided on April 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist hand orthosis (L3916) provided on February 4, 2021.
You asked the Plan to pay for a wrist hand orthosis. You say that this is supported by the records. The Plan denied your request. The Plan says this was provided following an unsolicited phone call.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a wrist hand orthosis (L3916) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on March 31, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 podiatry services provided on March 31, 2021 by a non-participating provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT of the head or brain (70450) provided on February 25,
2021.
You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says an appropriate NCCI modifier was not
billed with this procedure-to-procedure code edit.
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, we have confirmed that code the CT
of the head or brain has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot
be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for CT of the head or brain (70450) provided on
February 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a fitness tracker (A9270) received on December 29, 2020.
You asked the Plan to pay for a fitness tracker. You say that you were told you would be reimbursed for this item. The Plan denied your request. The Plan says the item at issue is not a covered benefit.
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's rules for coverage of gym benefits have not been met because fitness trackers are not a covered benefit.. Therefore, we decided that the Plan does not have to pay for a fitness tracker (A9270) received on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (G0008, 90662, 83036, 99213) provided on February 8, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 physician services (G0008, 90662, 83036, 99213) provided on February 8, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department (ED) services (99285) and electrocardiogram (ECG) interpretation and report (93010) provided on February 16, 2021.
You asked the Plan to pay for the ED visit and ECG report. You say that these services should not be bundled as the visits were distinct and provided by different physicians. The Plan denied your request. The Plan says that since one doctor from the same billing group with the same specialty provided critical care services on this date, this provider cannot be paid for ED services. Also, the code 93010 would need a modifier to be separately paid along with code 12011 which was provided by the other physician.
The Plan must follow Medicare rules. Medicare rules say that NCCI edits are applied to services provided to the same patient by the same physician on the same date. In this case, although the two physicians at issue have their services billed by the same billing entity and have the same specialty, the record clearly reflects that these services took place in completely different facilities. It is not appropriate to bundle payment for ED services provided at one hospital to critical care services provided at a different facility. The circumstances clearly reflect that the services are distinct. As such, denial of payment for these services is not supported. Therefore, we decided that the Plan has to pay for the emergency department (ED) services (99285) and electrocardiogram (ECG) interpretation and report (93010) provided on February 16, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 2, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerebral perfusion analysis using computed tomography with contrast administration (0042T) and computed tomography (CT) scan of head or brain (70460) provided April 22, 2021.
You asked the Plan to pay for the cerebral perfusion analysis using computed tomography with contrast administration and CT scan of head or brain. You say that you would like these claims reprocessed based on medical necessity. The Plan denied your request. The Plan says the claims have denied correctly in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that cerebral perfusion analysis is only covered for certain diagnoses. In this case, we have confirmed that the enrollee did not have a Medicare-approved diagnosis for the requested cerebral perfusion analysis. Therefore, the provided service is not eligible for coverage. In addition, we have confirmed that 70460 has a bundled relationship with code 0042T and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the cerebral perfusion analysis using computed tomography with contrast administration (0042T) and computed tomography (CT) scan of head or brain (70460) provided April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic (CT) angiography provided on February 3, 2021.

You asked the Plan to waive the copayment for the CT angiography. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a CT angiography on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $195 copayment for all other diagnostic and nuclear medicine radiological services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a CT angiography on February 3, 2021. You have been asked to pay a $195 copayment for the CT angiography. The CT angiography falls within the Outpatient diagnostic tests 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 computed tomographic (CT) angiography provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided by a provider not enrolled in the Medicare program on February 19, 2021.
You asked the Plan to pay for the durable medical equipment provided by a provider not enrolled in Medicare. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided by a provider not enrolled in the Medicare program on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup and endodontic therapy provided on February 8, 2021.
You asked the Plan to pay for the core buildup. You say that the services should be covered. The Plan denied your request. The Plan says the endodontic therapy was approved, and the core buildup is not a covered benefit.
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 core buildup and endodontic therapy provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the primary care physician (PCP) and Medicare Part B drug services rendered from September 10, 2020 to May 12, 2021.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was 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 20% coinsurance for Medicare Part B covered drugs and a $5 copayment for in-network PCP's office visits.
Review of the file shows that you received Part B drug services on September 10, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $0.35. These services fall within the Medicare Part B covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received PCP services on April 28, 2021 and May 12, 2021. You have been asked to pay a $5 copayment per date of service for these services, for a total of $10. These services fall within the PCP's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $10.35. 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 cost sharing for the primary care physician (PCP) and Medicare Part B drug services rendered from September 10, 2020 to May 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee will need 24-hour nursing for safety, patient/family education on disease processes, monitoring of vital signs, and medication administration. The Plan denied your request. The Plan says that the enrollee would benefit from home healthcare therapies on an intermittent basis.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the venipuncture provided on February 3, 2021 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 venipuncture provided on February 3, 2021 by a non-participating provider.