Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on September 9, 2020.  You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with 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 a $20 copayment for outpatient rehabilitation services.   You have been asked to pay a $20 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on May 21, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99326) rendered by the out-of-network (OON) provider on August 17, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.   We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of a new patient (99326) rendered by the out-of-network (OON) provider on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skin graft surgery of the nose performed on August 2, 2021.  You asked the Plan to waive the copayment for the nose surgery. You say that the surgery was medically necessary. 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 $325 copayment for each outpatient surgery at a hospital outpatient facility.   You have been asked to pay a $325 copayment for the nose surgery. The nose surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 skin graft surgery of the nose performed on August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 6, 2021, to July 12, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that the doctor punctured your lung, which made your inpatient hospital stay longer. 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 $300 copayment for days 1-5 for inpatient hospital care.   The record shows that you received inpatient hospital care from July 6, 2021, to July 12, 2021. Therefore, you are responsible to pay the total amount of $1,200, which is less than the total copayment amount.  You have been asked to pay the total copayment amount of $1,200 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from July 6, 2021, to July 12, 2021.   We note your complaint that the doctor punctured your lung which resulted in a longer stay. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hymovis.  You asked the Plan to pre-approve Hymovis. You say that this drug is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been satisfied.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. The rules also say that viscosupplementation therapy is subject to the criteria listed 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 Hymovis. Our reviewer says that the requested drug is not medically reasonable and necessary according to Medicare rules. Our physician reviewer found that you are a 68-year-old female with unilateral primary osteoarthritis of the right knee. You have been treated with a knee brace, oral analgesics (Ibuprofen), topicals (diclofenac gel), and supplements (Glucosamine chondroitin). You have had X-rays and magnetic resonance imaging of the knee which demonstrate osteoarthritis. Your provider has recommended viscosupplementation therapy with Hymovis.  In this case, there is no documentation that you have failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy. The review has determined that the documentation does not support the use of Hymovis based on the LCD. Hymovis is not medically reasonable or necessary for your condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an osseous surgery (D5261), and sales tax (D9985) provided by an out-of-network provider on June 21, 2021.  You asked the Plan to pay for an osseous surgery and sales tax. You say that you think the Plan should pay for this. The Plan denied your request. The Plan says the requested dental service 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 an osseous surgery (D5261), and sales tax (D9985) provided by an out-of-network provider on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for prophylaxis (D1110), and a period oral evaluation (D0120) provided by an opt out provider on June 29, 2021.  You asked the Plan to pay for prophylaxis and a period oral evaluation. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says the rendering dentist has opted out of Medicare.  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. The rendering physician has opted out of Medicare until September 23, 2022.      Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), and a period oral evaluation (D0120) provided by an opt out provider on June 29, 2021.
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 is not medically necessary.    The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.  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 response and treatment, no transport, (A0998) provided on May 22, 2021.  You asked the Plan to pay for the ambulance service. You say that the enrollee was not on hospice during the date of service. You say that this should be paid. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since there was no transport provided, there is not a payable service.  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 May 22, 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 the response and treatment, no transport, (A0998) provided on May 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on August 10, 2021.  You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that the test could not be completed because your heart rate increased too much. 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 $275 copayment for diagnostic radiology.   You have been asked to pay a $275 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for myocardial perfusion imaging provided on August 10, 2021.  We note your complaint that the test could not be completed. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 6, 2021 to September 16, 2021.  You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the Health Insurance Prospective Payment System (HIPPS) code submitted on the claim is invalid. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 6, 2021 to September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on September 28, 2020.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says coverage of the hearing mandatory supplemental benefit exclusion include any fee for any services rendered by a non-network hearing aid provider.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a network hearing or hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0367), pulp vitality tests (D0460), and problem focused limited oral evaluation (D0140) provided on October 21, 2021.  You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, and problem focused limited oral evaluation. You say that you were told that these services would be covered, and you would not have to pay for anything. The Plan denied your request. The Plan says the cone beam CT capture and interpretation and pulp vitality tests are not covered under the Plan. The Plan also says that the problem focused limited oral evaluation exceeds the maximum allowed per period.  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 cone beam CT capture and interpretation (D0367) and pulp vitality tests (D0460) are not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on May 25, 2021 and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0367), pulp vitality tests (D0460), and problem focused limited oral evaluation (D0140) provided on October 21, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for Coronavirus (COVID-19) testing provided on June 27, 2020.  You asked the Plan to pay for Coronavirus (COVID-19) testing. 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 Coronavirus (COVID-19) testing provided on June 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, and 87801 provided on May 19, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 CPT codes 87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, and 87801 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, and 87801 provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a specialist office visit provided on August 20, 2021.  You asked the Plan to waive the deductible for the specialist office visit. You say that you have had many intestinal issues and you feel that your concerns were not addressed. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $203 deductible which applies to Physician/Practitioner Services, Including Doctor's Office Visits.   The specialist office visit you asked the Plan to waive the deductible for falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $203 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on August 20, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a specialist office visit provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 7, 2021.  You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 7, 2021.