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

 We decided that the Plan does not have to pay for an office visit (99214) provided on September 20, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available. The services were not emergent or pre-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 service 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 an office visit (99214) provided on September 20, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 19, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you needed to find a new dentist that was handicap accessible. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the comprehensive oral exam once every 36 months. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam was previously covered on October 13, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided October 19, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 continues to require acute care services for his medical conditions and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on July 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that your doctor is a hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain proper authorization from the patient's insurance company. You also ask for the Plan to not penalize the doctor for the hospital staff's failure in taking the proper steps to obtain authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services were not urgent or emergent, nor were the 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 domiciliary or rest home visit (99336) provided on July 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit with wound debridement (99212, 11042, 11721) provided on June 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit with wound debridement. You say that you are resubmitting the claim as no authorization on file or available along with supporting documents. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider. The Plan also says they have also 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 an office visit with wound debridement (99212, 11042, 11721) provided on June 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on October 20, 2021.
You asked the Plan to waive the copayment for an EKG. You say that you never received the services on October 20, 2021. The Plan denied your request. The Plan says the enrollee received the service, and the proper copayment was 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 $40 copayment for Medicare covered diagnostic tests and procedures. The total amount allowed was $18.33 which is less than the copayment of $40. Therefore only $18.33 is charged for the copayment.
You have been asked to pay a $18.33 copayment for an EKG. An EKG 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 an electrocardiogram (EKG) provided on October 20, 2021.
Your complaint about your experience with this provider 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 20, 2021
.
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 provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) coded 70544
provided on September 15, 2021.
You asked the Plan to pay for the MRA. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the services billed are 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 70544
is a column II code to column I code 70553. 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 the magnetic resonance angiography (MRA) coded 70544
provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the anesthesia services coded 00732 provided on July 29, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered does not meet the coverage requirements in the Local Coverage Determination or National Coverage Determination.  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. Review of the file shows that the Plan states that these services are denied due to the services rendered not meeting the coverage requirements in the Local Coverage Determination (LCD) or National Coverage Determination (NCD). However, the Plan did not provide the LCD or NCD used to support this decision. There is no other documentation in the case file to support why these services were denied. This means the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the anesthesia services coded 00732 provided on July 29, 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: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the critical care services (99291) provided on July 7, 2021.  You asked the Plan to pay for the critical care services. You say that this claim has been billed appropriately based on the medical records submitted. The Plan denied your request. The Plan says that the documentation does not support the time spent providing critical care services.  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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.  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 the critical care services. Our reviewer says that the documentation submitted supports the critical care service 99291 as coded. Our reviewer found critical care documentation for date of service July 7, 2021, was found in the medical records submitted. Provider documents a thorough evaluation and management service and documented "Crit time so far>35 minutes."  No further documentation of critical care time was reported. Time spent for critical care services are billed once per day, even if the time spent by the physician is not continuous.  In this case, the physician documented critical care time "so far >35 minutes." Since no additional critical care was performed for this date of service, the appropriate code CPT 99291 would be reported. This physician documented the critical care given, with the time spent for that service, if additional critical care would have been provided for this date of service, provider would document the critical care given with the additional time spent.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the critical care services have been met. Therefore, we decided that the Plan has to pay for the critical care services (99291) provided on July 7, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc-One.  You asked the Plan to pre-approve Synvisc-One. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Synvisc-One. Our reviewer says that this drug is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternatives. The elements of the coverage criteria 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided on October 5, 2021.

You asked the Plan to waive the copayment for the physical therapy. You say that you were overcharged for the visit. 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 $20 copayment for each physical therapy visit. 

The file shows that the claim was updated to reflect the correct copayment responsibility. Therefore, you have been asked to pay a $20 copayment for the physical therapy. 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 services provided on October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital stays provided from July
23, 2021, to August 13, 2021.
You asked the Plan to waive the copayment for inpatient hospital stays. You say that you are being charged
two separate copayments for your inpatient hospital stay. The Plan denied your request. The Plan says the
claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for days 1-5 for each inpatient hospital admission.
You had an inpatient hospital stay from July 23, 2021, to August 3, 2021. Therefore, you are responsible to pay
a $350 copayment for days 1-5 (July 23, 2021, to July 27, 2021). The amount you owe for this stay is: $350
(copayment) x 5 (inpatient days) = $1,750.
You had an inpatient hospital rehabilitation stay from August 3, 2021, to August 13, 2021. This is considered a
new inpatient hospital admission.
Therefore, you are responsible to pay a $350 copayment for days 1-5 (August 3, 2021, to August 7, 2021). The
amount you owe for this stay is: $350 (copayment) x 5 (inpatient days) = $1,750.
The total amount you owe is: $3,500.
You have been asked to pay the total copayment amount of $3,500 for inpatient hospital stays. Inpatient
hospital stays fall within the inpatient hospital care benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for inpatient hospital stays provided from July 23, 2021, to August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 17, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as it was a primary care visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $40 copayment for Physician/Practitioner services, including doctor's office visits, specifically specialist visits.       You have been asked to pay a $40 copayment for a specialist office visit. The record indicates that the provider you saw is a specialist in obstetrics and gynecology. 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 specialist office visit provided on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic computed tomography scan of
the thorax without contrast material (71250) provided on August 31, 2021.
You asked the Plan to waive the copayment for a diagnostic computed tomography scan of the thorax without
contrast material. You say that the invoice you submitted with the appeal should have been paid in full based
on current requirements and your policy. 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 up to a
$50 copayment for each Medicare-covered diagnostic radiology service in an office setting or imaging center.
You have been asked to pay a $50 copayment for a diagnostic computed tomography scan of the thorax
without contrast material. A diagnostic computed tomography scan of the thorax without contrast material 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 a diagnostic computed tomography scan of the thorax without
contrast material (71250) provided on August 31, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 continues to improve with decreasing oxygen requirements but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.    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.