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

We decided that the Plan does not have to waive the $226.20 copayment charged for physician services (fine needle aspiration) provided on April 22, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says you are being charged less than the normal $295 copayment.

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 $295 copayment for outpatient hospital services.

In this case, you have been asked to pay less than the normal copayment expectation. 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 $226.20 copayment charged for physician services (fine needle aspiration) provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided to the enrollee on April 7, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for this code is always bundled into payment for other services not specified, and no separate payment is made per Medicare.
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 code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B" which means it cannot be reported separately. 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 anesthesia services (99100) provided to the enrollee on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded as 88305, 88312, 88311 and 87101 provided on March 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the pathology services. You say that please review the attached medical documentation that shows proof of services rendered by your laboratory. The Plan denied your request. The Plan says 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. 

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 surgical pathology services coded as 88305, 88312, 88311 and 87101 provided on March 1, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiological supervision and interpretation an angiography for bilateral extremity studies (75716) and selective angiography, for each additional vessel studied after basic examination radiological supervision and interpretation (listed separately in addition to code for primary procedure) (75774) provided October 15, 2020.
You asked the Plan to pay for diagnostic services. You say that you are attaching documentation to support the codes being denied. Please review and reconsider the decision for payment. The Plan denied your request. The Plan says this service is inclusive to the primary procedure. Ineligible for separate payment.
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 codes 75716 and 75774 has a bundled relationship with code 37227 and cannot be paid as billed. These codes cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiological supervision and interpretation an angiography for bilateral extremity studies (75716) and selective angiography, for each additional vessel studied after basic examination radiological supervision and interpretation (listed separately in addition to code for primary procedure) (75774) provided October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81291, 81407, and 81408) provided on June 24, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 test 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 laboratory services (81291, 81407, and 81408) provided on June 24, 2020.
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 enrollee would not be safe at home and needs at least two (2) people assisting them at all times. 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 the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on March 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that it is the nursing facilities responsibility to get authorizations. The Plan denied your request. The Plan says prior authorization was not obtained as required.

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 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 rest home visit provided on March 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services represented by code 81521 provided on November 23, 2020.
You asked the Plan to pay for code 81521. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says genetic testing procedures submitted under code 81521 is unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to pay for the laboratory services represented by code 81521 provided on November 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you think it is a good fit for the enrollee. The Plan denied your request. The Plan says the requested admission to an LTACH does not meet criteria.
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 the enrollee is receiving appropriate care at the present acute care hospital. 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. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on March 17, 2021 by an OON provider.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you did not know that this provider was not in-network with your plan. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that services are only covered by dentists who participate with your plan.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on March 17, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided April 30, 2021.
You asked the Plan to pay for the dental consultation. You say that there was no network provider in your area so you would like the claims from this date of service covered. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76705) provided May 3, 2021.
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan denied your request. The Plan says this service has a bundled relationship with another service 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. In this case, we have confirmed that code 76705 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76705) provided May 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on May 14, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy.. You say that there should be $0 copayment for a screening colonoscopy. 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 $345 copayment for diagnostic colonoscopies. You have been asked to pay a $345 copayment for the diagnostic colonoscopy. While it is true that under your contract screening colonoscopies do not have a copayment, the records show that you did not have a screening colonoscopy. The records show that you had a diagnostic colonoscopy due to a diagnosis of diverticulosis. 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 diagnostic colonoscopy you had on May 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on April 20, 2021.
You asked the Plan to pay for the physical therapy services. You say that the code submitted is valid and correctly identifies the service rendered. You say that the claim should be considered for reimbursement. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the billed services.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a physician assistant. As such, PT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on April 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care.
Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found recent notes did not suggest you had a medical history that would expect a complicated hospital course. The documentation did not support the you would require hospital services that would likely cross 2 midnights for this lower risk procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital admission and services received March 22, 2021, to March 26, 2021, and March 26, 2021, to April 2, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital admissions and services. You say that you should only be charged one copayment for a continuous hospital stay. The Plan denied your request. The Plan says you were correctly charged copayments for 2 separate hospital admissions.
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 $350 copayment per day, days 1-5 for each Medicare hospital admission/stay. Your inpatient cost sharing will apply each time you are admitted. This includes when transferring from one facility to another or within the same
facility between levels of care. You have been asked to pay a total of $1,400 ($350 copayment x 4 days = $1,400) for the first inpatient hospital admission and $1,750 ($350 copayment x 5 days = $1,750) for the second inpatient hospital admission. The inpatient hospital admissions fall within the Inpatient hospital care benefit category. The case file included medical records showing that you were discharged from your initial hospital stay and admitted to Long Term Acute Care on March 26, 2021. Since you were admitted under a different level of care, a second copayment was appropriately applied. 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 copayment for the inpatient hospital admission and services received from March 22, 2021, to March 26, 2021, and March 26, 2021, to April 2, 2021.
Your complaint about the way the inpatient stays were billed and the copayment policy when transferring to a different level of care 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 copayment for the hospital outpatient clinic visit (G0463) provided on April 6, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 Medicare-covered non-surgical visit in an outpatient clinic. 

You have been asked to pay a $128.35 copayment for the Medicare-covered non-surgical visit provided in an outpatient clinic.

This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 hospital outpatient clinic visit (G0463) provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), spherocylinder single vision lenses (V2103) and polycarbonate lenses (V2784) provided on May 18, 2021.
You asked the Plan to pay for eyeglass frames and lenses. You say that you were told the frames would be free after cataract surgery. The provider's office advised you that you were entitled to a free frame. You also say the insurance company should state how much money is given for the free frames. The Plan denied your request. The Plan says the diagnosis code was not for post cataract eyewear.
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 contract says that you receive one pair of eyeglasses or contact lenses after each cataract surgery. Eyewear must be obtained within 12 months of cataract surgery. Only Medicare-covered basic frames and lenses are covered. We looked at the file and the Plan's rules. The records show that you received deluxe frames and lenses on May 4, 2021, and the Plan paid over the $100 benefit limit. The records also show you exhausted your maximum allowed benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, single vision lenses and polycarbonate lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), spherocylinder single vision lenses (V2103) and polycarbonate lenses (V2784) provided on May 18, 2021.