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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services were not inherently complex or require a registered nurse to perform.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for proton therapy provided on January 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for proton therapy. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.
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 proton therapy provided on January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy 60 minutes (90837) provided on February 15, 2021 by an out-of-network (OON) telehealth provider.
You asked the Plan to pay for the telehealth psychotherapy services. You say that you have rendered treatment to the enrollee in good faith that the service will get reimbursed. The Plan denied your request. The Plan says Medicare payment for clinical psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with patient consent, and consult with the attending or primary care physician There was no documentation of one or more of the criteria.
Medicare rules says Medicare payment for clinical psychologist's services via telehealth is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with patient consent, and consult with the attending or primary care physician. You can find this in the Medicare MLN Booklet,
Medicare Mental Health, https://www.cms.gov/files/document/medicare-mental-health.pdf. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychotherapy 60 minutes (90837) provided on February 15, 2021 by an out-of-network (OON) telehealth provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy provided on April 8, 2021.
You asked the Plan to waive the copayment for a biopsy. You say that you did not know until you received an itemized statement that the claim included a $350 copayment for a biopsy. You also stated you were not aware that a biopsy is considered a surgical procedure and subject to the copayment. 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 $350 copayment for Medicare-covered outpatient surgery.
You have been asked to pay $195.76, which is less than the $350 copayment for a biopsy. A biopsy is considered a surgical procedure and falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 biopsy provided on April 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 10, 2020 to June 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from June 10, 2020 to June 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided March 6, 2021.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code
billed. CPT 99284 is more appropriate.
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 99285 is an emergency room visit with a comprehensive
history, comprehensive examination and complex medical decision-making.
We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not
support that the medical problem was complex in nature.
Based on this information, we decided that Medicare rules for coverage of the emergency room services have
not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285)
provided March 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from January 7, 2021, to January 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that if you would have known you were going to be charged, you wouldn't have gone through with these services. 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 $325 copayment per day for days 1-5 for inpatient hospital care. Records show that you were in the hospital for two days. You have been asked to pay a $325 copayment per day for the inpatient hospital services, for a total of $650. 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 services you received from January 7, 2021, to January 9, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine transportation. You say that you need additional routine transportation to get to your appointments. The Plan denied your request. The Plan says you have exhausted your routine transportation benefit. Enrollees are allowed 24 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the request for transportation beyond the 24 one-way trips provided by the Plan exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 21, 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 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 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 out of network physician services provided to the enrollee on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on April 9, 2021.

You asked the Plan to pay for the refraction. You say that this should be covered. The Plan denied your request. The Plan says no eye exam was billed with the refraction.

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 when provided during a routine eye exam. 

We looked at the file and the Plan's rules. The requested eye refraction was not provided during a routine eye exam. The Plan does not cover eye refractions provided without a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for presumptive drug testing (80305) Eligible clinician attests to
documenting in the medical record they obtained, updated, or reviewed the patient's current medications
(G8427) provided July 10, 2020.
You asked the Plan to pay for the acupuncture services. You say that you do not understand why the codes
were denied. The Plan denied your request. The Plan says this provider has not submitted any clinical records
to support the medical necessity of the services provided. The services are considered incidental to other
clinical services and not eligible for additional payment.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the health Plan contract specifically says that
acupuncture services is not covered. Therefore, we decided that the Plan does not have to pay for presumptive
drug testing (80305) Eligible clinician attests to documenting in the medical record they obtained, updated, or
reviewed the patient's current medications (G8427) provided July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a health club membership
provided on January 17, 2020.
You asked the Plan to reimburse you for the health club membership. You say that it is not your fault that the
mail delayed the delivery of your reimbursement form. You say that you did mail the reimbursement form
before the March 31st deadline. The Plan denied your request. The Plan says that the Plan approved $112.33.
However, there was no proof of payment received for $37.67. Therefore, since we have received proof of
payment one day after the deadline, you are entitled to and will be reimbursed $112.33. We must deny the
remainder of your request since no proof of payment was received.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because there was no proof of payment received for $37.67. Therefore, we decided that the Plan does not have to reimburse you an additional amount for a health club membership provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a nasal interface mask and accessories
provided from February 23, 2021, to May 24, 2021.
You asked the Plan to waive the coinsurance for a nasal interface mask and accessories. You say that you are
unable to pay the invoices 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 20%
coinsurance for Durable Medical Equipment (DME) and Related Supplies.
You have been asked to pay $116.87 in coinsurance, which is 20% of the allowed amount for nasal interface mask and accessories.
Claim Number:
Date of Service:
Allowed Amount:
20% Coinsurance:
780262107793044
2/23/2021
$300.61
$60.13
780262107793051
3/8/2021
$26.33
$5.27
780272114610504
5/24/2021
$88
$17.60
780282114618842
5/24/2021
$3.33
$0.67
780282114619150
5/24/2021
$29.87
$5.97
Total:
$584.27
$116.85
Nasal interface mask and accessories falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a nasal interface mask and accessories provided from February 23, 2021, to May 24, 2021.
Your complaint about how often you have to appeal 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 cardiovascular risk assessment provided on October 3, 2020.
You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
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, the cardiovascular risk assessment, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The submitted documentation does not include any clinical information to verify why this testing was ordered and how it will affect the member's treatment. Additionally, these services have not been billed with the appropriate CPT codes for cardiovascular risk assessment. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on October 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior
(D2394) for tooth #29 provided May 24, 2021.
You asked the Plan to pay for the composite filling for tooth #29. You say that you would like the service
covered. The Plan denied your request. The Plan says this service was previously covered by the Plan and you
were not eligible for a new filling at the time of 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 composite
filling for tooth #29 once every 3 years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a composite filling
for tooth 29 was previously covered on April 26, 2021. Based on this information, we determined that the
Plan's frequency limit for coverage of the composite filling for tooth #29 has been exceeded. Therefore, we
decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior
(D2394) for tooth #29 provided May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99153) provided to the enrollee on
February 13, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by Medicare coding regulations.
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 99153 is "Moderate sedation services provided by the
same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; each additional 15 minutes of intra-service time
(List separately in addition to code for primary service)."
We find that CPT code 99153 is not supported in the medical record. Specifically, this code may not be paid if
furnished to a hospital inpatient or patients in a hospital outpatient department. 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 pay for anesthesia services (99153) provided to the
enrollee on February 13, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the services (G2023) provided on March 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that payment for this service is included in the payment for another service.
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. The Plan has not provided documentation showing that payment for code G2023 is included in the payment of another service. The Plan's argument alone does not support its claim, nor does it specify which service payment was included in. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (G2023) provided on March 14, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental. More research is needed to show safety and efficacy of the intracept procedure for the treatment of back pain. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.