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

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on June 3, 2021.
You asked the Plan to waive the copayment for ophthalmological services. The Plan denied your request. The Plan says the correct copayment was applied to the claim.
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 $25 copayment for Vision Care. You have been asked to pay a $25 copayment for ophthalmological services. The ophthalmological services falls within the Vision 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 ophthalmological services provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted dialysis procedure coded 90999 and the etelcalcetide injection coded J0606 provided from November 3, 2020 to November 28, 2020.

You asked the Plan to pay for the unlisted dialysis procedure and the etelcalcetide injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the unlisted dialysis procedure coded 90999 and the etelcalcetide injection coded J0606 provided from November 3, 2020 to November 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator you received on February 21, 2021.
You asked the Plan to waive the coinsurance for the bone growth stimulator. You say that you were led to believe that insurance would cover this at no cost to you. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the bone growth stimulator. The bone growth stimulator falls within the durable medical equipment 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 bone growth stimulator you received on February 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83036, 85610) provided March 19, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue 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. 

We find that CPT code 83036, & 85610 is not supported in the medical record. Specifically, payment for these services was included in payment to the facility and these services are not separately payable. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (83036, 85610) provided March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 27, 2021.

You asked the Plan to pay for the laboratory services. 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 payable.

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 laboratory testing 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 April 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) mental health provider.

You asked the Plan to pre-approve the continuation of care with an OON mental health provider. You say that you should be able to continue seeing the requested OON provider because you have a long-standing relationship with them. You say that ending your treatment with this provider would cause your condition to worsen. The Plan denied your request. The Plan says all medically necessary treatment is available and accessible to the enrollee within the network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 continuation of care with an OON mental health provider. Our reviewer says that the criteria for coverage with an OON provider have not been met. Our physician reviewer found the enrollee suffered from Schizophrenia Spectrum Disorder and Major Depressive Disorder, Recurrent, Mild. Based on review the records provided, the enrollee has been stable with no suicidal or homicidal ideation. The enrollee does not require treatment by an out-of-network provider as the medical plan is able to provide a psychotherapist for the treatment of the enrollee's condition. This enrollee's condition is not considered to be an urgent/emergent condition. The Plan has shown that the enrollee has in-network specialists who have the qualifications and expertise necessary to meet the current Standards of Care required for treatment of the enrollee's condition. The enrollee's medical management and follow-up care can safely be transitioned to an in-network specialist at this time. 

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 continuation of care with an OON mental health provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with an out of network (OON) mental health provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits.
You asked the Plan to pre-approve the additional PT visits. You say that it is felt that additional therapy would benefit the enrollee's functional level. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has a diagnosis of lumbar disc disease with back pain. PT was initiated on 5/20/2021. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment beyond what has been provided. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for eyeglasses (V2100, V2784, V2715, V2025) provided on May 25, 2021.
You asked the Plan to pay the full cost for eyeglasses. You say that you needed these eyeglasses. The Plan denied your request. The Plan says this processed correctly.
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 offers $100 toward the purchase and fitting of eyeglasses. You are responsible for any amount of the retail price over $100. We looked at the file and the Plan's rules. The record shows that the retail price for the eyeglasses at issue was $396. You have been asked to pay $236.80 after the $100 benefit and a discount was applied, meaning that you have been assessed the correct responsibility according to your contract. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay the full cost for eyeglasses (V2100, V2784, V2715, V2025) provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service represented by code 81455 provided on April 1, 2021.
You asked the Plan to pay for code 81455. 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory service represented by code 81455 provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided on June 23, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 lab services (G0482) provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation coded 99255 provided on August 31, 2020.
You asked the Plan to pay for the inpatient consultation. 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 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, the CPT Code Manual definition of code 99255 is inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 110 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99255 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation coded 99255 provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on March 26, 2021.

You asked the Plan to reimburse you for eyeglasses. The Plan denied your request. The Plan says you must go to a participating network provider, and you did not have an approved authorization on file for a non-plan provider.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a participating network provider. 

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a participating network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on March 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician direction of emergency advanced life support
paramedic services (99288) provided on March 14, 2021.
You asked the Plan to pay for the physician direction of emergency advanced life support paramedic services.
You say that the member was seen twice on the same date. The Plan denied your request. The Plan says these
services are always bundled into another service or procedure.
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 99288 is physician or other qualified health care
professional direction of emergency medical systems (EMS) emergency care, advanced life support.
We find that CPT code 99288 is not supported in the medical record. Specifically, CPT code 99288 has a status
indicator of B meaning that payment for this service is always bundled into another procedure. Separate
payment is not made for CPT code 99288. Based on this information, we decided that Medicare rules for
coverage of the physician direction of emergency advanced life support paramedic services have not been met.
Therefore, we decided that the Plan does not have to pay for the physician direction of emergency advanced
life support paramedic services (99288) provided on March 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive arrhythmia and cardiomyopathy genetic panel (81215, 81201, 81162, 81408, 81406, 81405, 81403, 81401, 81323, 81321, 81319, 81317, 81300, 81298, 81297, 81295, 81294, 81292) provided on December 16, 2019.
You asked the Plan to pay for a comprehensive arrhythmia and cardiomyopathy genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive arrhythmia and cardiomyopathy genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive arrhythmia and cardiomyopathy genetic panel (81215, 81201, 81162, 81408, 81406, 81405, 81403, 81401, 81323, 81321, 81319, 81317, 81300, 81298, 81297, 81295, 81294, 81292) provided on December 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided by a Licensed Professional Counselor (LPC) on March 9, 2021.
You asked the Plan to pay for the behavioral health 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 when provided by a Licensed Professional Counselor.
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. The rules also say that a licensed professional counselor is not eligible to enroll in Medicare.
Review of the file and Medicare records indicates that the provider at issue is not eligible to be enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided by a Licensed Professional Counselor (LPC) on March 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 18, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 18, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from October 18, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 18, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond October 18, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from October 18, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 18, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) and core buildup, including any pins when required (D2950) provided on June 3, 2021.
You asked the Plan to pay for the resin-based composite and core buildup. You say that you were shocked when you went to pay your copay of $608.00 for services that you did not authorize the provider to do. The Plan denied your request. The Plan says these services are not covered.
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 resin-based composite (D2392) and core buildup, including any pins when required (D2950) provided on June 3, 2021.
Your complaint about not authorizing the dentist to complete the services 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.