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

We decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a second opinion office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician's visit with a specialist (99397) provided on December 7, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for a physician's visit with a specialist. You say that you were not aware that you needed a referral for this doctor. The Plan denied your request. The Plan says this provider is not a network provider, and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have determined that these services are not urgent or emergent, nor were they approved in advance.

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 a physician's visit with a specialist (99397) provided on December 7, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 16, 2020, by an out-ofnetwork provider.

You asked the Plan to pay for the out-of-network services. You say that you were not aware that the provider 
did not request an authorization. You state if you would have known you would have not had the surgery. The 
Plan denied your request. The Plan says the services were for a scheduled knee surgery and were not 
emergent/urgent. The Plan states the services are available within the network and the facility is not contracted 
with either the health plan. The Plan states you have been a member with this health plan since November 1, 
2016. The Plan states you did not present yourself to the facility nor the surgeon as having insurance with this 
health plan, instead you presented yourself as having Original Medicare. The Plan states 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 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 services provided on December 16, 2020, by 
an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from July 16, 2021, through July 30, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that there was no change or notification in 2021 that physical therapy at a participating provider would be different. You say that $40 should not be charged. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit.
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $160 ($40 copayment/visit x 4 visits = $160). Physical therapy falls 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 physical therapy provided from July 16, 2021, through July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee has not finished their full course of care in the hospital. The Plan states the enrollee is not medically stable to transfer to another level of care. The Plan states the enrollee has a new plastic tube placed in their chest for uncontrolled buildup of fluid around the lungs. The Plan states there have not been many attempts made to see if they can safely breathe on their own. The Plan states the settings on the mechanical breathing machine do not reflect that the enrollee is stable to transfer to another facility for prolonged weaning trials. The Plan states the enrollee can safely receive the care in their current hospital setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital.

The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 20,
2021.

You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date
of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.

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 CPT code 70450 was billed with code 70496 on the date of service at issue. We find that
CPT code 70450 may be eligible for payment when billed with this code pair. The claim information does not
show that the code at issue was billed with a modifier suitable for payment. 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 computed tomography (CT) scan provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045) provided August 26, 2021.
You asked the Plan to pay for radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed has a bundled relationship with another code billed and 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 71045 is a column II code to column I code 71046. 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 radiology services (71045) provided August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on March 11, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code 99291 (1 Unit) remains not supported. CPT code 99291 represents critical care, evaluation and management of the critically ill or critically injures patient, first 30-74 minutes. The documentation submitted do not include a critical care progress note for the billed date of service of March 11, 2021; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided to the enrollee on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shower chair.

You asked the Plan to pay for a shower chair. You say that the item was medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88321) provided on May 18, 2021.
You asked the Plan to pay for laboratory services. You say that you are billing only for the professional component, which is separate from what was previously paid. The Plan denied your request. The Plan says this is a duplicate claim,
The Plan must follow Medicare rules. Medicare rules say that if the billing physician or other supplier performs only the technical component or the professional component and wants to bill for both components of the diagnostic test, the TC modifier and 26 modifier must be reported as separate line items if billing electronically or on separate claims if billing on paper. We looked at the file and Medicare rules. The appeal indicates that the professional component is being billed, but the service was not reported with modifier 26.
Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88321) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the lenses provided on May 11, 2021.

You asked the Plan to pay more for the lenses. You say that they tried to get the lenses right and they kept adding more cost as they tried to get it right. You say that you paid $300 and want to be reimbursed. The Plan denied your request. The Plan says only $100 will be covered from an in-network provider.

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 toward eyeglasses every year. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the eyeglasses have not been met. Specifically, the Plan paid $100 toward the glasses purchased on May 11, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the lenses provided on May 11, 2021.

Your complaint about poor workmanship 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on May 21, 2021.

You asked the Plan to waive the coinsurance for the Part B drug. You say that this should be fully covered by your medical plan. 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% coinsurance for in-network Medicare Part B covered drugs. 

You have been asked to pay $923.87 which is 20% of the allowed amount for the Part B drug. The allowed amount is $4,619.34. ($4,619.34 x 20% = $923.87). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drug provided on May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from December 31, 2021, 
forward.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care from December 31, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care (99226) provided on September 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for subsequent observation care. You say that the patient was seen at an in-network facility and did not get to choose their provider. The Plan denied your request. The Plan says this provider is a non-participating provider and that there is no referring provider for the member. The plan also says that the services were not authorized by network/primary care providers.

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 subsequent observation care (99226) provided on September 21, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the recliner chair purchased on September 2, 2021.

You asked the Plan to pay for the chair. You say that you are requesting reimbursement of services rendered. 
You state that you were advised that the lift mechanism is covered but your chair was purchased at a retail 
furniture store. The Plan denied your request. The Plan says the rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the chair have not been met. This store is not a DME vendor it is a 
retail sore. Your 2021 EOC states DME purchased at a retail store is not a covered benefit. 

Furthermore, the rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pay for the 
recliner chair purchased on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation hospital stay provided by a participating provider on August 3, 2021, to August 11, 2021.

You asked the Plan to waive the copayment for an inpatient rehabilitation hospital stay. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care. 

You have been asked to pay a $295 copayment per day for days 1-6. There is a $0 copayment for additional days for an inpatient rehabilitation hospital stay. The total amount you are being asked to pay is $1,770 ($295 x 6 days = $1,770). The correct copayment has been applied to the inpatient hospital stay that was provided. An inpatient rehabilitation hospital stay 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 an inpatient rehabilitation hospital stay provided by a participating provider on August 3, 2021, to August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the enrollee can receive the care they need in another setting, such as home, a long-term care facility, or other outpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 14, 2021.

You asked the Plan to waive the copayment for the laboratory services. You say that you feel the copayment is unfair since it needs to be done three days prior to your appointment. 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 $10 copayment per day for laboratory tests that are not fecal immunochemical tests (FIT).

You have been asked to pay a $10 copayment for the laboratory services. Please note that this charge would still apply even if it had been done on the same day as your primary care appointment. Laboratory services fall 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 laboratory services provided on May 14, 2021.