Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92014) provided on September 3, 2021, by an 
out-of-network (OON) provider.

You asked the Plan to pay for an eye exam. You say that the enrollee was in a nursing home setting at the time 
of service. You also say that the enrollee could not choose an in-network provider since no other provider was 
allowed into the facility during the Covid 19 pandemic. You also say that since most enrollees require urgent 
care, it is not possible to request authorization before services are rendered. The Plan denied your request. The 
Plan says it was determined the services were not urgent or emergent. An authorization was not requested or 
obtained prior to the services being rendered. The Plan also says that the enrollee must receive their treatment 
from network providers.

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 contract says that you must use a participating network provider for vision care.

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The 
Plan covers an eye exam when services are received from a provider who participates in the Plan's specified 
vision network. Based on this information, we decided that the Plan's rules for coverage of an eye exam have 
not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92014) provided on 
September 3, 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 an office visit (99214) provided on July 2, 
2021.

You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
it was a wellness visit The Plan denied your request. The Plan says the cost-sharing applied correctly based on 
the services 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 $10 
copayment for Physician/Practitioner services, including doctor's office visits. 

You have been asked to pay a $10 copayment for an office visit. The record indicates that this was billed as 
primary care visit. 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 an office visit (99214) provided 
on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from June 10, 2021, through
July 9, 2021.

You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF services do 
not meet Medicare coverage criteria as there were no daily skilled nurse or therapist need.

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 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. His lungs were clear. His appetite was 
good. Regarding rehabilitation services, the enrollee received physical therapy (PT) at a non-skilled level of 
care three times per week. He was noted to be up and able to ambulate ad lib and independent. There are no 
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee 
does 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pay for SNF services provided from June 10, 2021, through July 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that your home isn't set up for therapy and you don't
have someone available to help you. The Plan denied your request. The Plan says that the services you require
can safely be received at a different setting.
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 your 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rasagiline.

You asked the Plan to pre-approve Rasagiline. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rasagiline.

Benefits for Rasagiline 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 the additional periapical x-ray (D0230) provided on August 
20, 2021.

You asked the Plan to pay for the additional periapical x-ray. You say that you had to change providers. You 
say that your previous provider left the network. You say that you received a bill for the services you received. 
also say that you cannot afford to pay this. The Plan denied your request. The Plan says 1 periapical x-ray is 
covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 and periapical x-ray is listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical xray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to 
pay for the additional periapical x-ray (D0230) provided on August 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on June 30,
2021 and billed under codes S1015 and S8301.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare guidance says code codes S1015 and S8301 have a status code of "I" meaning
this code is not used on Medicare claims.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. The codes billed are not payable on Medicare
claims. Medicare uses a different code to report these services.
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for home health services provided to the enrollee on June 30, 2021 and billed under code S1015
and S8301.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 28, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the methocarbamol provided in an outpatient setting on 
August 3, 2021.

You asked the Plan to pay for the self-administered drug. You say that you went to the emergency room. You 
say that you knew you would have a $90 copay. You say that you were unaware you had to pay for the 
medication too. You also say that the medication should be covered. The Plan denied your request. The Plan 
says the drug you received is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under
Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the methocarbamol provided in 
an outpatient setting on August 3, 2021.

Benefits for the self-administered drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care services provided from July 16, 
2021, through August 27, 2021.

You asked the Plan to waive the copayment for wound care services. You say that you were told that you owed 
nothing for each visit upon check-in. You say that you could not have continued with wound care services if 
you were told there was a $175 charge per visit. 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 $175 for 
each Medicare-covered outpatient stay at a hospital facility. Covered services include services in an emergency 
department or outpatient clinic, such as observation services or outpatient surgery. 

You have been asked to pay a total of $1,825.24 for the wound care services. 

Date of Service                 Service                       Standard Copayment     Member Liability
July 16, 2021                  Wound Care Services        $175                              $175
July 19, 2021                  Wound Care Services       $175                             $108.79
July 21, 2021                  Wound Care Services       $175                             $108.79
July 23, 2021                  Wound Care Services       $175                             $164.50
July 27, 2021                  Wound Care Services       $175                             $108.79
July 30, 2021                  Wound Care Services       $175                             $164.50
August 3, 2021               Wound Care Services       $175                             $108.79
August 6, 2021               Wound Care Services       $175                             $164.50
August 10, 2021             Wound Care Services       $175                             $108.79
August 13, 2021             Wound Care Services       $175                              $175
August 17, 2021             Wound Care Services       $175                             $108.79
August 20, 2021             Wound Care Services       $175                             $164.50
August 27, 2021             Wound Care Services       $175                             $164.50

TOTAL:                                                                                                         $1,825.24

The wound care services fall within the "Outpatient hospital services" benefit category. Wound care is 
considered a surgical service. 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 wound care services 
provided from July 16, 2021, through August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (85060) provided on July 27, 2021.
You asked the Plan to pay for code 85060. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we decided that the Plan does not have to pay for the laboratory services (85060) provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 26, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on May 26, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. 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 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 based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his reported level of pain, decreased endurance and hypoxia with exertion. Care at the skilled nursing facility level appears to be appropriate in this case. 

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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport rendered on January 12, 2021.

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 payment is included in the inpatient DRG.

The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective payment systems are payment in full for all inpatient hospital services. 

We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was under inpatient hospital status. Payment for these services is included in payment to the hospital. Therefore, we decided that the Plan does not have to pay for the ambulance transport rendered on January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 21, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare requires providers to submit a valid taxonomy code for claim
payment. In this case, we have confirmed the taxonomy code submitted is not a valid code for the National
Provider Identifier (NPI) number entered on the claim. The NPI submitted on the claim shows a different
taxonomy code assigned to this provider. Therefore, we decided that the Plan does not have to pay for the
ambulance services provided on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 13, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for laboratory services provided to the enrollee on July 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on February 9, 2021.

You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contract providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the records do not indicate if the rendering provider was a physical therapist or PTA. A nurse practitioner is not able to bill for the services of a PTA because the nurse practitioner is not a therapist. There is no evidence that the nurse practitioner was on the premises to be able to bill for PT services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Retacrit injections provided from June 23, 2021, through August 10, 2021.

You asked the Plan to waive the coinsurance for the Retacrit injections. You say that you already paid $20 per visit and are not paying this bill. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B- covered drugs.

You have been asked to pay a total of $313.66 for the Retacrit injections.

The Retacrit injections fall within the "Medicare Part B Prescription Drugs" 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 Retacrit injections provided from June 23, 2021, through August 10, 2021.