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

We decided that the Plan does not have to pay for the flow cytometry, interpretation; 16 or more markers
(88189) rendered by the out-of-network (OON) provider on January 28, 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 flow cytometry, interpretation; 16 or more markers (88189) rendered by the out-ofnetwork
(OON) provider on January 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the YAG laser capsulotomy procedure you had at an outpatient hospital facility on July 28, 2020.

You asked the Plan to waive the copayment for the outpatient eye surgery. You say that this was a follow-up procedure to a cataract operation. You said that you do not understand why you are getting a bill for this procedure. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for surgery or other services at an outpatient hospital facility. 

You have been asked to pay a $295 copayment for the outpatient eye surgery. This is a separate and distinct surgery from the original cataract surgery, so a separate copayment applies. You had this procedure at an outpatient hospital facility, so the outpatient eye surgery falls within the surgery or other services at an outpatient hospital facility 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 YAG laser capsulotomy procedure you had at an outpatient hospital facility on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 13, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 out of network physician services provided on July 13, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the bladder irrigation provided on February 1, 2021.

You asked the Plan to waive the copay for these services. You say that you were informed you would not have any outstanding payment due. The Plan denied your request. The Plan says that the claim processed correctly according to your plan benefits.

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 $260 copay for each Medicare-covered outpatient hospital services. 

You have been asked to pay a $113 copay for these services. These services fall within the Medicare-covered outpatient hospital services benefit category. This means that you have been asked to pay less than 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 copay for the bladder irrigation provided on February 1, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the cerumen removal provided during a nursing home evaluation on April 9, 2021.
You asked the Plan to pay for the cerumen removal. You say that these services were provided in good faith during a skilled nursing stay at the network facility. The facility is the custodian of these records. The Plan denied your request. The Plan says that the diagnosis code is not appropriate for this service.
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. The case file submitted by the Plan lacked a case narrative. The only evidence of the rationale for denial of this service was the remittance advice. This indicates that payment for the cerumen removal was denied as the diagnosis code was not consistent with the procedure. Review of the claim shows that the diagnosis was reported as G35 (impacted cerumen, right ear). We find that this diagnosis code clearly supports the services rendered. Without a valid argument in support of non-payment, we find this denied is not substantiated. Therefore, we decided that the Plan has to pay for the cerumen removal provided during a nursing home evaluation on April 9, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on April 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. In this case, there is no referring physician on the claim and the records do not show that the CP consulted the enrollee's PCP. 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 the outpatient mental health services provided on April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided by a certified occupational therapy assistant (COTA) on November 20, 2019.

You asked the Plan to pay for OTA visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's service because they do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. This service performed by an OTA is being billed under a nurse practitioner (NP). Based on this information, we decided that Medicare rules for coverage of OTA visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit provided by a certified occupational therapy assistant (COTA) on November 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042), muscle and/or fascia debridement (11043), and chemical cauterization of granulation tissue (17250) provided on July 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the debridements and chemical cauterization of granulation tissue. You say that these services were rendered due to medical necessity and patient care was provided as an urgent request. The Plan denied your request. The Plan says the OON provider did not get health plan approval for these services. The Plan also says that these services were not an emergency and there were in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042), muscle and/or fascia debridement (11043), and chemical cauterization of granulation tissue (17250) provided on July 2, 2021 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the requested drug is covered under the enrollee's part D plan.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Benefits for Rituxan 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 more for the eyewear provided on May 27, 2021. 
 
You asked the Plan to pay more for the eyewear. You say that you were informed you could improve your 
vision if you had your glasses upgraded. You say that insurance should want you to see better, and you are 
appealing the denial of charges. The Plan denied your request. The Plan says the maximum allowance has been 
paid. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $100 every year for eyewear. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Specifically, the Plan paid the maximum annual allowance of $100 
toward the eyewear purchased on May 27, 2021. Therefore, we decided that the Plan does not have to pay more 
for the eyewear provided on May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) any 
joint of upper extremity (73221) provided April 29, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic service. You say that these medical charges are 
too expensive for you. Please help to lower your cost. Please help you to lower your cost. The Plan denied your 
request. The Plan says the claim was processed with the correct copayment applied per the Evidence of 
Coverage. 
 
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 $350 
copayment for diagnostic radiology other than CT scans. 

You have been asked to pay $350 copayment for the diagnostic service. The diagnostic service 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 the magnetic resonance imaging (MRI) any joint of upper extremity (73221) 
provided April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 26, 2021.

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 the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional speech therapy (ST) visits.

You asked the Plan to pre-approve the additional ST visits. You say that patients do not do vital stimulation
protocol independently at home. You also say that the patients need the electrical stimulation device and a
speech therapist to administer the modality in the clinic. The Plan denied your request. The Plan says additional
ST is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional ST visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as
specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The
enrollee has had prior extensive therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to provide treatment safely and effectively, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer found
that the enrollee has been instructed in and is compliant in a home exercise program. Our physician reviewer
also found that the requested services are not part of a maintenance program, are the specialized skill,
knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to
maintain the enrollee's current condition or to prevent or slow further deterioration.

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 additional ST visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve eight (8) additional speech therapy (ST) visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a patient lift purchased on May 31. 2021. 
 
You asked the Plan to pay for this equipment. You say that the Plan should reimburse you for this equipment. 
The Plan denied your request. The Plan says you did not have prior authorization for this equipment. 
 
Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says 
that durable medical equipment requires prior authorization. The Plan did not pre-approve the item purchased. 
Therefore, we decided that the Plan does not have to pay for a patient lift purchased on May 31. 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth, completely bony, (D7240) 
provided on June 14, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied 
your request. The Plan says removal of an impacted tooth is not listed and therefore is not a covered service. 
 
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 removal of an impacted tooth is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of an impacted tooth, completely bony, (D7240) provided on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lifevest provided from February 22, 2021 to April 22, 2021.

You asked the Plan to waive the coinsurance for the lifevest. You say that you were never told this would cost you anything. The Plan denied your request. The Plan says that 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 a 20% coinsurance for Durable medical equipment (DME) and related supplies. 

You have been asked to pay a 20% coinsurance for the lifevest. The lifevest falls 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 waive the coinsurance for the lifevest provided from February 22, 2021 to April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services 
provided from February 18, 2021, through March 19, 2021. 

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continued SNF services are not medically necessary. 
 
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 continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of 
admission, the enrollee required skilled rehabilitation services to improve function due to weakness and 
deconditioning. There were no skilled nursing needs.  As of February 17, 2021, the enrollee did not require any 
skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within 
a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient 
basis, at a SNF level of care as of February 17, /2021. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; 
however, his function had plateaued by February 17, 2021, and he did not require any further inpatient skilled 
rehab services. The enrollee's function was at or near his prior level of function and he could be discharged to a 
lower level of care for further services. As of February 17, 2021, the enrollee required custodial services. The 
denial for further inpatient skilled care is upheld.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from  
February 18, 2021, through March 19, 2021.