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

We decided that the Plan does not have to pay for the assisted living facility visit provided on June 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON assisted living facility visit. You say that the provider relies on the facility to get authorization for services. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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. It is the provider's obligation to confirm the patient's insurance coverage prior to rendering services. 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 assisted living facility visit provided on
June 18, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are still receiving skilled nursing care and need assistance improving your mobility. The Plan denied your request. The Plan says your SNF benefits are currently exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from May 3 - October 30, 2021. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on July 31, 2021.
You asked the Plan to pay for the radiology services. You say that the patient revoked their hospice election on July 21, 2021. The Plan denied your request. The Plan says the patient was enrolled in hospice on the date of service.
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 July 21, 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 radiology services provided on July 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system (L5920).
You asked the Plan to pre-approve an alignable system. You say that this is medically reasonable and necessary. The Plan denied your request. The Plan says there is no reason why the current alignable system you have would not be sufficient.
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 an alignable system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found An alignable system (L5920) exceeds the patient's medical need and is not medically necessary per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury
or to improve the functioning of a malformed body member. There is no evidence of damage or wear to the prior alignable system. The medical progress notes do not indicate that the patient is unable to use the prior alignable system with his most recent approved socket. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an alignable system have not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system (L5920).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for chiropractic services you received on May 6, 2021.  You asked the Plan to waive the copayments for the chiropractic services. You say that you never would have gone to this appointment if you had known you would have had to pay for it. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for chiropractic services.   You have been asked to pay a $20 copayment for the chiropractic 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 copayments for chiropractic services you received on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 95955, 95861, 95937, 95927, and 99508 provided on March 19, 2021.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the services as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the codes are: 95955 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 95861 - Needle electromyography; 2 extremities with or without related paraspinal areas 95937 - Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 95927 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 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 medical services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found the documentation that was provided, specifically the technical report, does not include documentation of the billed services. These procedures cannot be verified given the provided documentation. 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 medical services have not been met.
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 95908 is a column II code to column I code 95861. This claim pairing has a modifier of 0 which indicates modifiers will not be allowed. 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 medical services coded as 95955, 95861, 95937, 95927, and 99508 provided on March 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac catheterization services provided at an outpatient hospital facility on May 27, 2021.
You asked the Plan to waive the copayment for the cardiac catheterization. You say that this procedure had to be rescheduled. You do not feel as though you should have to pay this copayment since this service could have been done while you were an inpatient. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $350 copayment for the cardiac catheterization. The cardiac catheterization falls
within the outpatient surgery in an outpatient hospital facility benefit category. This copayment applies regardless of the reason why this procedure was done on an outpatient basis. 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 cardiac catheterization services provided at an outpatient hospital facility on May 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 28, 2021.
You asked the Plan to pay for the services provided. You say that the modifier is considered payable. The Plan denied your request. The Plan says the claim was not billed according to Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code A0429 is Ambulance service, basic life support, emergency transport. We find that CPT code A0429, billed with a -QL modifier is not supported in the medical record. The records show that rigor mortis was noted. There were no resuscitation attempts due to obvious death. The records provided do not indicate the enrollee died after the ambulance had been called, but before it arrived. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 28, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vascular study coded as 93976 provided on July 20, 2021.  You asked the Plan to pay for the vascular study. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed with this PTP code edit.  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 93976 is a column II code to column I code 76856. 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 vascular study coded as 93976 provided on July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit and screening mammography provided from May 26, 2021, through June 28, 2021.
You asked the Plan to pay for the annual wellness visit and screening mammography. You say that you were not aware the benefit for these services had been exhausted. The Plan denied your request. The Plan says the benefit for these services had already been exhausted.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. The Plan contract says that the plan will cover a screening mammogram every 12 months. Based on review of the file, an AWV and a screening mammogram was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit and screening mammography provided from May 26, 2021, through June 28, 2021
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 18, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on January 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier, provided on April 23, 2021.
You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier. The Plan denied your request. The Plan says the claim was not billed according to CMS guidelines. The provider billed HCPCS code A0429 with QL modifier. The records indicate the member was pronounced dead after the ambulance was called.
The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier, provided on April 23, 2021.
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 enrollee needs care in the IRF to gain strength and to walk on her own. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for non-surgical management of pelvic fractures after a motor vehicle accident. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pay for the excision of a benign lesion (D7410) provided on June 9, 2021.
You asked the Plan to pay for the excision. You say that this was a medical service and should be covered by the medical benefit. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
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. Medicare rules also say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 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. The provider in this case is a dentist and the service at issue was billed with a dental code. You say that this was a medical service and not dental, but medical records were not provided to support this statement and verify medical necessity. Therefore, we decided that the Plan does not have to pay for the excision of a benign lesion (D7410) provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the Eylea injection and the scanning computerized ophthalmic diagnostic imaging you received on June 3, 2021.
You asked the Plan to waive the cost sharing for the Eylea injection and the scanning computerized ophthalmic diagnostic imaging. You say that that the doctor used a different drug that is much more expensive. You stated that you do not think you should be charged because the doctor didn't have the original drug on your appointment date. The Plan denied your request. The Plan says you were charged these cost sharing amounts 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 Medicare Part B drugs and a $20 copayment for other services with an ophthalmologist.
You have been asked to pay 20% coinsurance for the Eylea injection and a $20 copayment for the scanning computerized ophthalmic diagnostic imaging. This coinsurance applies regardless of the reason why you received this drug. The Eylea injection falls within the Medicare Part B drugs benefit category. The scanning computerized ophthalmic diagnostic imaging is an ophthalmology service. This means that you have been asked to pay the correct amounts 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 cost sharing for the Eylea injection and the scanning computerized ophthalmic diagnostic imaging you received on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on June 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 medical services provided to the enrollee on June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy procedure you had at an outpatient hospital facility on July 22, 2021.
You asked the Plan to waive the copayment for the biopsy procedure. You say that you were told that your copayment would only be $40. The Plan denied your request. The Plan says it looked at the phone records and it shows that you were told that you would have a $40 copayment for podiatry services, not for the outpatient surgery you had. The Plan says that you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery at an outpatient hospital facility.
You have been asked to pay a $350 copayment for the biopsy procedure. The biopsy procedure falls within the
outpatient surgery at an outpatient hospital facility 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 biopsy procedure you had at an outpatient hospital facility on July 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation provided on June 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON physical therapy evaluation. You did not provide an argument in your appeal request, rather, you just stated that you would like to appeal and you provided medical records. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 physical therapy evaluation provided on June 3, 2021, by an out-of-network (OON) provider.