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

 We decided that the Plan does not have to reimburse you for the diagnostic laboratory testing (99199) provided on April 10, 2021.  You asked the Plan to reimburse you for the diagnostic laboratory testing. You say that you were not advised that the services would not be covered. You say that you received a letter from the plan to get an annual preventive screening. You also say that you do not understand why this would not be covered. The Plan denied your request. The Plan says the provider in this case is not certified to participate in Medicare. The Plan says that services received by a provider that does not participate in Medicare are not payable.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Additionally, the record shows that the provider in this case does not participate in the Medicare program and the cost of the screening service are not covered or reimbursable by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the diagnostic laboratory testing (99199) provided on April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) and the mechanical traction therapy (97012) provided on May 13, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services provided are not a covered benefit under the member's contractual policy.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) and the mechanical traction therapy (97012) provided on May 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit provided on May 12, 2021.  You asked the Plan to pay for the home visit. You say that Medicare shows hospice was terminated on May 11, 2021 and the denial should be reviewed. The Plan denied your request. The Plan says Original Medicare is responsible for payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on May 9, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the home visit provided on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).  You asked the Plan to pre-approve IRF care. You say that more rehabilitation is needed to prevent decrease in function. The Plan denied your request. The Plan says the services can be safely received in other settings.  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 you are medically stable with no complex medical conditions to address and no other complexity. There is no need for physician supervision three times a week in an IRF. There are no acute rehabilitation nursing needs.  Based your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You need physical and occupational therapy in an alternate lower intensity level.  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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) provided August 19, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that your 2022 Annual Notice of Changes only mentions the change in cost-sharing for air ambulance. The Plan denied your request. The Plan says the copayment was 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 $290 copayment per date of service for ground ambulance. You had one ambulance trip. The Plan charged you $290 for these services. 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 ambulance services (A0427) provided August 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from September 21, 2020, to September 29, 2020,.
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 that the DRG was updated in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with . 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 the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found the enrollee is a female with Parkinson's disease admitted to the hospital after falling using her walker injuring her face and right elbow. A secondary diagnosis code, E43 (severe protein-calorie malnutrition) was listed but removed by the Plan. Upon evaluation the patient was "well-nourished." However, albumin was listed as 2.6 and husband reported a weight loss of 100 pounds over 6-7 months due to significantly reduced by mouth (PO) intake. There was sufficient support made for DRG 492 as the enrollee meets the ASPEN criteria for severe malnutrition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from September 21, 2020, to September 29, 2020,.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cinacalcet rendered from February 3, 2021 to June 30, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The Plan must follow Medicare rules. The rules say that all drugs and biologicals used for the treatment of end-stage renal disease (ESRD) are included in the ESRD PPS and are not separately paid as of January 1, 2011.  We looked at the file and Medicare rules. The drug was rendered for the treatment of ESRD. The services are not separately payable. Therefore, we decided that the Plan does not have to pay for the Cinacalcet rendered from February 3, 2021 to June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Orencia.  You asked the Plan to pre-approve Orencia. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Orencia.   Benefits for Orencia 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided January 19, 2021 to April 9, 2021.  You asked the Plan to pay for the home care services. You say that the necessary paperwork had been submitted for reimbursement for the home health care services, which is medically necessary. The Plan denied your request. The Plan says the home health services were rendered by a non-participating, non-Medicare certified provider and is therefore not covered the Plan.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for home health aide or certified nurse assistant, providing care in the home; per hour (S9122) provided January 19, 2021 to April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care services (99233) provided December 16, 2019.  You asked the Plan to pay for hospital care services. You say that please see attached supporting documentation to support untimely filing due to the enrollee not providing proper insurance information. Please reconsider the untimely filing denial and process the claim for payment. The Plan denied your request. The Plan says the corrected claim was received past the timely filing limitation.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for hospital care services was not filed until July 9, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services (99233) provided December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (36415, 85610) rendered by the out-of-network (OON) provider on August 19, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 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 laboratory services (36415, 85610) rendered by the out-of-network (OON) provider on August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is functioning at a home care level and does not require daily skilled therapy to restore or maintain function.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a comprehensive eye examination provided on March 17, 2021.  You asked the Plan to waive the copayment for the comprehensive eye examination. You say that you were told you would have a $0 copayment. The Plan denied your request. The Plan says the claim processed with the correct copayment based on your Evidence of Coverage for a Medicare-covered vision services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Medicare-covered vision services.    You have been asked to pay a $30 copayment for the comprehensive eye examination. The comprehensive eye examination falls within the Vision Care, Medicare-covered vision 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 a comprehensive eye examination provided on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for revascularization procedures (37220, 37222) and an atherectomy (0238T-XS) provided on April 28, 2021.  You asked the Plan to pay for revascularization procedures and an atherectomy. You say that these codes are supported. The Plan denied your request. The Plan says these codes are not documented.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 37220 is revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty. The definition of 37222 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure). The definition of 0238T is transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel.  We asked our coder 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 revascularization procedures and an atherectomy. Our reviewer says that these codes are not supported. Our reviewer found there is not documentation of the revascularization procedures coded as 37220 and 37222. The operative report does not include documentation to support 0238T had been performed on a separate organ or structure to confirm the use of Modifier XS.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization procedures and an atherectomy have not been met. Therefore, we decided that the Plan does not have to pay for revascularization procedures (37220, 37222) and an atherectomy (0238T-XS) provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received on June 22, 2021.  You asked the Plan to waive the copayment for the lab services. You say that when you go for your annual exam, you doctor should tell you that you will have to pay for the labs so you are not surprised by the bill. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for these lab services ($9.71) is less than your copayment obligation, you are responsible for the full allowed 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 for lab tests.   You have been asked to pay a $10 copayment for the lab services. The lab copayment applies any time you have lab services, even if done in conjunction with your annual visit. 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 lab services you received on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a visual field examination (92083) rendered on July 19, 2021.  You asked the Plan to waive the copayment for a visual field examination. You say that you do not think you should have to pay a specialist copayment when you did not see the doctor. You also say these visits used to be done the same day before the coronavirus (Covid-19) and you did not have to pay two copayments before. The Plan denied your request. The Plan says you were 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 $35 copayment for Vision Care.    You have been asked to pay a $35 copayment for a visual field examination. Visual field examinations fall within the Vision Care benefit category. The records show that even though you did not see a provider, services were rendered. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a visual field examination (92083) rendered on July 19, 2021.   Your complaint about the provider potentially separating your vision exam into two appointments 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health office visits provided on March 27, 2020 to April 30, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visits. You say that you have been seeing this provider for 2 years and is very happy with the therapeutic relationship. 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 outpatient mental health office visits provided on March 27, 2020 to April 30, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the general health panel rendered on November 10, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code.  You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on November 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve BioZorb insertion following lumpectomy for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this request will not covered as the doctor indicates that a lumpectomy will happen.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee is having a lumpectomy, not mastectomy. The elements of the coverage rule are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve BioZorb insertion following lumpectomy for the enrollee.