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

 We decided that the Plan does not have to pay for the outpatient office visit (99203) Unclassified drugs (J3490) provided on February 10, 2021 by an out-of-network (OON) provider in Hong Kong.  You asked the Plan to pay for the office visit. You say that you have macular degeneration. This was a well respected doctor in Hong Kong and you needed the procedures to save your eyesight. The Plan denied your request. The Plan says non-emergent services in Hong Kong is not covered. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The services were non-emergent outpatient services. 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 outpatient office visit (99203) Unclassified drugs (J3490) provided on February 10, 2021 by an out-of-network (OON) provider in Hong Kong.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on December 7, 2020.

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 procedure codes 95957, 95908, and 95885 are not supported.

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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). 

We find that CPT codes 95957, 95908, and 95885 are not supported in the medical record. Specifically, there is no documentation of digital analysis of EEG for epileptic spike analysis to support code 95957. There is no documentation of 3-4 nerve conduction studies to support code 95908. There is no documentation of needle electromyography to support code 95885. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on December 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from May 9, 2021, to May 11, 2021.  You asked the Plan to pay for the self-administered drugs. You say that the medication you received in the hospital were medications that you take normally. You also say that you were not allowed to bring your own from home. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are 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 self-administered drugs provided in an outpatient setting from May 9, 2021, to May 11, 2021.   Benefits for the self-administered drugs 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 intraoral radiographic imaging (D0220 and D0230) provided on August 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for intraoral radiographic imaging. You say that you were told that they accepted your insurance. The Plan denied your request. The Plan says services must be provided by a participating provider or prior authorization must be 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 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 intraoral radiographic imaging (D0220 and D0230) provided on August 16, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reduce the coinsurance for the compression stockings provided on August 10, 2021.  You asked the Plan to reduce the coinsurance for the compression stockings. You say that your out-of-pocket cost for both pairs have been $80.46. You say your Explanation of Benefits reads as if you received four pairs of stockings and you have only received two pairs. 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 20% of the cost for each Medicare-covered item.   You have been asked to pay $80.46 which is 20% of the allowed amou9nt for each of the compression stockings. The allowed amount is $402.30. ($402.30 x 20% = $80.46). ($80.46 + $80.46 = $160.92). The compression stockings fall within the "Durable medical equipment (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 reduce the coinsurance for the compression stockings provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2313, E2313, E2377) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches, which are included in the allowance of these power options.  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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2300 seat elevator is not primarily medical in nature and is  not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. In terms of E2311, E2313 and E2377 - the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's wheelchair has three power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The patient's upper extremity strength and function with ability to feed and groom herself support that the enrollee can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2313, E2313, E2377) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the JAK2 gene analysis provided on October 30, 2020.  You asked the Plan to pay for the JAK2 gene analysis. 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 JAK2 gene analysis 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 JAK2 gene analysis provided on October 30, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee's nursing, medical and rehabilitation needs are not significant enough to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires rehab which can be continued at the current acute care hospital and continued at a skilled nursing facility when appropriate.  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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 1, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that the enrollee and the Plan should not be responsible for paying this claim. 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 $110 copayment for each covered emergency room visit.    The enrollee has been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. 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 emergency room visit provided on September 1, 2021.   Your complaint that the hospital insufficiently fastened the enrollee's belt is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on March 24, 2021.

You asked the Plan to pay for the services provided. You say that the pathology report supports the services billed. The Plan denied your request.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and the rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. The file shows that the enrollee was an inpatient at the time the services were provided. The services at issue were provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. 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 pathology services provided on March 24, 2021
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on June 15, 2021.  You asked the Plan to pay for the medical equipment. You say that you would like this claim reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says this claim has been billed with CPT codes that are invalid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that a code with a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes  In this case, the CPT Code Manual definition of code S1015 is IV tubing extension set. The CPT Code Manual definition of code S8301 is infection control supplies, not otherwise specified.  We find that CPT codes S1015 and S8301 are not eligible for payment. Specifically, these codes both have a status indicator of "I" under the Physician Fee Schedule which indicates that the codes in question are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical trays (A4550) provided on April 17, 2021.  You asked the Plan to pay for surgical trays. You say that this should be covered. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Code A4550 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for surgical trays (A4550) provided on April 17, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pay for the home health services provided from February 12, 2020, to February 29, 2020.  You asked the Plan to pay for the home health services. You say that the services should be covered. The Plan denied your request. The Plan says that non-contracted providers may not balance bill.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, you are being billed by the provider because the Plan states that they have not received a valid claim. The Plan has not forwarded any claims for us to verify if they were billed appropriately. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the home health services provided from February 12, 2020, to February 29, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 14, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you were there for a procedure and should not be charged for a specialist. The Plan denied your request. The Plan says you have been charged 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 $30 copayment for each specialist visit. 

You have been asked to pay a $30 copayment for the specialist office visit. This is a separate charge from the procedure. 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 June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis (L1851).  You asked the Plan to pre-approve the knee orthosis. You say that the brace is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that a knee orthosis is covered for recent injury or surgery, and in cases of knee instability.  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 knee orthosis. Our reviewer says that the requested knee brace is not medically necessary. Our physician reviewer found the record does not indicate that there has been recent injury or surgery. The physical examination demonstrates stability rather than instability of the knee.  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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on April 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the genetic testing. 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 genetic testing provided on April 30, 2021, by an out-of-network (OON) provider.