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

We decided that the Plan does not have to pay for the pathology services provided on June 14, 2021 by an out-of-network (OON) provider.  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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 pathology services provided on June 14, 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 the office visit provided on September 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you needed this appointment to renew your prescription. You say you have no control over which physician the group practice assigned on that particular day. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided on September 27, 2021, by an out-of-network (OON) provider.   Your complaint about the quality of the Plan's service 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit provided on July 15, 2021.  You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the evidence of benefits is required from the primary insurer.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on June 7, 2021.  You asked the Plan to pay for critical care services. You say that this is separately payable. The Plan denied your request. The Plan says this cannot be paid without a modifier.  The Plan must follow Medicare rules. Medicare rules say that where physicians agree on the transfer of care during the global period modifier "-55" is used for postoperative management. Modifier "-25" is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made.  We looked at the file and Medicare rules. The service at issue was billed in the postoperative period of a minor procedure, but it was not billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on September 8, 2021, by an OON provider.  You asked the Plan to pay for a complete upper denture and a complete lower denture. You say that you believe you should not be financially responsible for this claim as you were never told about the Plan's dental provider. You are requesting reconsideration of payment. The Plan denied your request. The Plan says the cost-share you are being charged is correct.  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.  We looked at the file and Medicare rules. The EOC confirms that your costs will be lower if you are treated by a dentist that participates in the Plan's network. The Plan's network dentists accept the maximum benefit amount payable by the plan for preventative services as payment in full. The EOC also confirms that when you receive services from an OON provider, your Plan pays the allowance or the dentist's charges, whichever is less. Specifically, you have been asked to pay the correct cost-share. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture and a complete lower denture have not been met. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower denture (D5120) provided on September 8, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 3, 2021.  You asked the Plan to pay for the eye refraction. You say that you were experiencing medical issues and blurriness in your eye, and this service was medically necessary. The Plan denied your request. The Plan says you had a previous eye refraction provided in February 2021. This service may only be covered once per year.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once per calendar year when they are received as part of a routine eye exam.  We looked at the file and the Plan's rules. Documentation indicates that the eye refraction was provided for medical purposes. The record also shows that you had a previous eye refraction performed in February 2021. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on June 29, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that no payment was made by the Plan on the approved charges. 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 $160 copayment for diagnostic radiological services, not including X-rays.   You have been asked to pay $97.80, which is less than the $160 copayment for the CT scan. Please note that the Plan would only be responsible for charges that exceed the copayment amount. The CT scan 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 computed tomography (CT) scan of the abdomen and pelvis provided on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 28 hours of home health aide (HHA) services (G0156) per week.  

You asked the Plan to pre-approve the 28 hours of HHA services per week. You say that you cannot do many things at home and need assistance. The Plan denied your request. The Plan says the HHA service is limited to members that require a skilled level of care and your needs can be met with a less complex service.  

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 28 hours of HHA services per week. Our reviewer says that these services are not medically reasonable and necessary. Our physician reviewer found the services of a HHA are not shown to be medically necessary to assist in the treatment of an illness or injury. Our reviewer also found that the requested HHA services appear to be custodial and, therefore, are not reasonable or coverable.  

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 28 hours of HHA services per week have not been met. Therefore, we decided that the Plan does not have to pre-approve 28 hours of home health aide (HHA) services (G0156) per week.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided from August 6, 2021, to August 13, 2021.  You asked the Plan to waive the copayments for the ER visits. You say that you feel you should only be responsible for one copayment since the visits were for the same incident. 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 $110 copayment for each emergency room visit.     You have been asked to pay $84.24, which is less than the $110 copayment for each ER visit. The total for the two visits is $168.48 ($84.24 copayment x 2 visits = $168.48). The ER visits falls within the Emergency 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 copayments for emergency room (ER) visits provided from August 6, 2021, to August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 10, 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 separately payable.  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 laboratory services provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultralightweight wheelchair (CPT code K0005), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show they are not a full-time wheelchair user. The Plan states the enrollee has not had a specialty evaluation and there is no reason the enrollee could not use an alternative wheelchair (K0001-K0004).  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 DME. Our physician reviewer found according to Medicare a manual wheelchair can be medically necessary when the beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming and bathing in customary locations in the home. The beneficiary's home provides adequate access for maneuvering a manual wheelchair and the beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. According to Medicare a high strength lightweight wheelchair is covered when a beneficiary is able to self-propel the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard wheelchair or the beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, light weight or hemi-wheelchair, and spends at least two hours per day in the wheelchair. A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months. In this case, the documentation doesn't support that the enrollee requires an ultralightweight wheelchair or that they are unable to accomplish mobility-related self-care tasks with an alternative assistive device.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve ultralightweight wheelchair (CPT code K0005), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided October 20, 2020, to October 29, 2020.  You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you would like the inpatient stay covered. 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 $500 copayment per inpatient hospital admission.   You have been asked to pay a $500 copayment for the inpatient hospital admission. The inpatient hospital admission falls within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided October 20, 2020, to October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary or rest home visit (99337) provided on August 6, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that the facility requests your providers to see their patients and you should fall under their authorization if one is needed. The Plan denied your request. The Plan says the referral was not authorized by the primary care provider (PCP). The Plan also says that this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that 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 domiciliary or rest home visit (99337) provided on August 6, 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 copayments for infusion therapy services provided from May 12, 2021, to May 23, 2021. We also decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on May 21, 2021.  You asked the Plan to waive the copayments for the infusion therapy services and the CT scan. You say that you are on a limited income and you feel that the partial coverage is unfair. 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 $295 copayment per day for surgery and other services provided at an outpatient hospital.   Your contract with the Plan also clearly says that you must pay a $155 copayment for radiological diagnostic services, not including X-rays.  The record shows that you have a total of 12 infusion therapy visits. You have been asked to pay $243.06 per visit, which is less than the $295 copayment per day for the infusion therapy services. The total for the infusion therapy services is $2616.72 ($243.06 copayment x 12 visits = $2916.72). The infusion therapy services falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay a $155 copayment for the CT scan. CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total amount for the infusion therapy services and the CT scan is $3071.72. 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 copayments for infusion therapy services provided from May 12, 2021, to May 23, 2021.  We also decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (80053) and the travel allowance one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient (P9604) rendered by the out-of-network (OON) provider on August 6, 2021.  You asked the Plan to pay for the 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 service (80053) and the travel allowance one way in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient (P9604) rendered by the out-of-network (OON) provider on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure to treat chronic vertebrogenic pain (CPT code(s): 22899, C9753, and C9752), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.  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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no exam provided of the lumbar spine. Detailed documentation is not evident regarding a normal neurological exam (as there are no recent lumbar spine objective exams documented.) The enrollee also does have subjective complaints of his legs feeling week. The magnetic resonance imaging (MRI) dated January 10, 2021, did indicate Modic type 1 endplate signal changes/edema at L3-4 and multilevel degenerative endplate signal changes especially prominent at L3-4 through L5-S1. However, multiple other plausible pain generators including at the lumbosacral spine are evident as plausibly corroborated by the noted MRI. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for intracept procedure to treat chronic vertebrogenic pain (CPT 22899 and C9752) at L3, L4, and L5 is not medically reasonable or necessary.  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 the intracept procedure to treat chronic vertebrogenic pain (CPT code(s): 22899, C9753, and C9752), for the enrollee.