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

 We decided that the Plan does not have to pay for skin sealants, protectants, moisturizers, ointments, any type provided on July 18, 2021.  You asked the Plan to pay for skin sealants, protectants, moisturizers, ointments, any type. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for skin sealants, protectants, moisturizers, ointments, any type provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of a new patient (99203) provided on August 2, 2021.  You asked the Plan to pay for the office visit services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed as required by Medicare coding regulations.  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 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.  We find that CPT code 99203 is not supported in the medical record. Specifically, according to Medicare rules it is inappropriate to bill a service as with a "new patient" if the provider has seen the enrollee within the last 3 years. The provider has multiple dates of service with the enrollee within the last 3 years. Therefore, the patient would not be considered a "new patient" on this date of service in question. Based on this information, we decided that Medicare rules for coverage of the office visit services have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of a new patient (99203) provided on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay in full for the four bitewing x-rays (D0274) provided on September 13, 2021.  You asked the Plan to pay in full for the four bitewing x-rays. The Plan denied your request. The Plan says benefits have been paid on the least costly method of treatment (two bitewing x-rays). The Plan also says that you are responsible for the difference between the allowed amounts.  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. The contract clearly states that the Plan only covers a set of two bitewing x-rays. Therefore, we decided that the Plan does not have to pay in full for the four bitewing x-rays (D0274) provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME provided on May 31, 2021.  You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because the Plan should be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 0% coinsurance for Medicare covered items with a total rental or purchase price of $350 or less of the Medicare allowable rate per item and 20% coinsurance for Medicare covered items with a total rental or purchase price of $350.01 or more of the Medicare allowable rate per item for DME and related supplies.   You received DME on May 31, 2021. The total allowed amount is $700 and 20% of that is $140.  You have been asked to the total coinsurance amount of $140 for DME. DME falls within the DME and related 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 coinsurance for DME provided on May 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020.  You asked the Plan to pay for the laboratory 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 rules say that providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Nursing Facility POS 32. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for anticoagulant management provided on April 9, 2021.  You asked the Plan to waive the copayment for anticoagulant management. You say that you were told that you would not owe a copayment and you are not going into the office to receive this service. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for services received by a Level 1 specialist.   You have been asked to pay the allowed amount of $10.23, which is less than the $35 copayment for anticoagulant management. Anticoagulant management falls 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 anticoagulant management provided on April 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the SNF stay provided from June 5, 2021, to June 24, 2021.   You asked the Plan to waive the copayment for the SNF stay. You say that the enrollee cannot pay for the 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1 to 20 and a $170 copayment per day for days 21 to 100.   The enrollee has been asked to pay a $1,909.31 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. See chart below.  Dates of Service Service SNF Days Copayment Day Count Member Liability May 12, 2021, to May 28, 2021 SNF care 1-16 $0 16 $0 June 5, 2021, to June 8, 2021 SNF care 17-20 $0 4 $0 June 9, 2021, to June 24, 2021 SNF care 21-36 $170 15 $1,909.31 - This is less than the standard amount because the enrollee met their maximum out-of-pocket amount. Total     $1,909.31  This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay provided from June 5, 2021, to June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on June 29, 2021.  You asked the Plan to pay for the services provided. You say that the medical documentation supports the billed services. The Plan denied your request. The Plan says the effectiveness has not been established in peer-reviewed literature.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that a NutraPharmaceutical injection was provided. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.  The file shows that electrical nerve stimulation was provided. The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) provided October 12, 2021.  You asked the Plan to pay for the vaccine services. You say that you believe that you should be reimbursed for the vaccine you received. The Plan denied your request. The Plan says this vaccine is not covered under your medical benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the vaccine services. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) provided October 12, 2021.   Benefits for the vaccine services 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 an eye refraction provided on August 12, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by the Plan if performed by participating provider and performed as a routine vision screening.  The Plan follows Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.   We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on August 12, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 9, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be billed for a follow-up for the same issue that was ordered by the doctor. 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 $90 copayment for each in- and out-of-service area Medicare-covered emergency room visit.      You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit  falls within the "Emergency care" 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 emergency room visit provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 10, 2020.  You asked the Plan to waive the copayment for the specialist office visit. You say that you left the office with no information regarding the upcoming surgery or diagnosis. 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 $45 copayment for visit to an in-network specialist.    You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you had a complete office 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 the specialist office visit provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for functional evaluation testing provided on January 26, 2021.  You asked the Plan to pay for functional evaluation testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the clinical value and effectiveness of functional evaluation testing for the enrollee's condition has not been demonstrated.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 functional evaluation testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has lumbago and cervicalgia. The provided records do not establish the reasonableness and necessity of functional evaluation testing.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of functional evaluation testing have not been met. Therefore, we decided that the Plan does not have to pay for functional evaluation testing provided on January 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428, A0425) provided on March 30, 2021.  You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you were transported without consent. The Plan denied your request. The Plan says the copayment 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 $275 copayment for ambulance services.   You have been asked to pay a $212.25 copayment for non-emergency ambulance services. The services at issue fall within the ambulance services benefit category. Since the Allowed Amount for this service is less than the required copayment of $275, you have been asked to pay only $212.25. 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 non-emergency ambulance transportation (A0428, A0425) provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray provided on July 13, 2021.  You asked the Plan to pay for the panoramic x-ray. You say that if you had known this service would not be covered you would have refused this x-ray. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, full mouth or panoramic x-rays share a frequency limitation of one procedure code per calendar year. The record shows that you received a complete series of intraoral x-rays on July 13, 2021 and your full mouth or panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on July 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremity (73701), abdomen and pelvis (74177) and chest (71260).  You asked the Plan to pre-approve the CT scans. You say that you believe the requested CT of the lower extremity, abdomen, pelvis and chest is medically necessary and beneficial to the enrollee. The Plan denied your request. The Plan says the criteria is not met because it is only supported once every three months for two years, and then once every six months for three years.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has a history of stage II melanoma of the lower extremity in 2014. The record indicates that the enrollee had a CT abdomen August 16, 2021 and an MRI of the abdomen on August 21, 2021. The record indicates the enrollee underwent CT scan in November 2020 that did not reveal any concern for recurrence. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. The elements of the coverage criteria are not satisfied.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the lower extremity (73701), abdomen and pelvis (74177) and chest (71260).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for office visits provided by an opted-out physician on May 5, 2021 and May 6, 2021.  You asked the Plan to pay for office visits. You say that you previously had approval for this treatment, but it expired, and you are still trying to get authorization approved. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare coverage and is not payable.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office visits provided by an opted-out physician on May 5, 2021 and May 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from July 9, 2021, to July 26, 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's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.  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 July 9, 2021, to July 26, 2021.