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

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. 

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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80048) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on October 7, 2021.
You asked the Plan to pay for these 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 services (36415, 80048) and the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental anesthesia.

You asked the Plan to pre-approve the dental service. You say that the anesthesia is medically necessary. The Plan denied your request. The Plan says routine dental services are not covered by the plan.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dental anesthesia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department service (99285) provided on December 31, 2020.

You asked the Plan to pay for the emergency department service. You say that you would like reconsideration because you should not be held liable for these services. The Plan denied your request. The Plan says they have no jurisdiction over the billing practices of out-of-network providers.

The Plan must follow Medicare rules. Medicare rules say that there is no balance billing paid by either the plan or the enrollee when the services are rendered by an out-of-network provider.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department service have not been met. Specifically, the record indicates that these services were rendered by an out-of-network provider. The Plan paid the provider the Medicare allowed amount for these services. The Plan is not responsible for paying the balance. Please contact your Medicare Regional Office with questions regarding balance billing. Therefore, we decided that the Plan does not have to pay for the emergency department service (99285) provided on December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing (81291, 81479) provided on May 26, 2021.

You asked the Plan to pay for GeneSight testing. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing (81291, 81479) provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abutment-supported cast metal crowns (D6062) for teeth #13, #14, #15 and #16.

You asked the Plan to pre-approve abutment-supported crowns. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are 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.

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 pre-approve abutment-supported cast metal crowns (D6062) for teeth #13, #14, #15 and #16.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).

You asked the Plan to pre-approve the orthotic device. You say that this enrollee has exhausted the other available therapies and has not regained meaningful use of his left upper extremity. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient domiciliary, rest home visit (99326) provided
on July 14, 2021, by an OON provider.

You asked the Plan to pay for the domiciliary, rest home visit. You say that it is the nursing facilities
responsibility to get authorizations for their patients. It was medically necessary for the enrollee to receive
treatment and you did not know the facility failed to get preauthorization. The Plan denied your request. The
Plan says enrollee's must receive their medical services from an in-network provider with the exception being
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization
before services being rendered.

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 new patient domiciliary, rest home visit
(99326) provided on July 14, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2021.

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 not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extracapsular cataract removal (66984) provided from April 20, 2021 to April 29, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for extracapsular cataract removal. You say that these claims were denied because the referral was absent, and you included the referral with the appeal. The Plan denied your request. The Plan says this provider is a nonparticipating provider as well as the ordering provider. The Plan also said that the services received were not emergent/urgent and were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 extracapsular cataract removal (66984) provided from April 20, 2021 to April 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient laryngoscopy provided on July 27, 2021
You asked the Plan to waive the copayment for the outpatient laryngoscopy. You say that the services should be covered as they were simple and quick. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Outpatient hospital services.
You have been asked to pay a $150 copayment for an outpatient laryngoscopy. Laryngoscopies fall within the Outpatient hospital services benefit category and the record indicates that these services were performed in an outpatient setting. 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 outpatient laryngoscopy provided on July 27, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 7, 2021.

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 not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections (64483).
You asked the Plan to pre-approve the epidural steroid injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period. We looked at the file and Medicare rules. This request would exceed the limit of 4 sessions of steroid injections per spinal region in a 12-month period. Based on this information, we decided that Medicare rules for coverage of the epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (64483).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 11 physical therapy (PT) visits.
You asked the Plan to pre-approve the additional PT visits. You say that you believe that more therapy is needed to reach your goals. The Plan denied your request. The Plan says ongoing therapy is 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 additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy of 24 outpatient visits with an additional 1 visit approved to reinforce a home exercise program (HEP). The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been instructed in and is compliant in the HEP. 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 an additional 11 physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on August 27, 2021.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that the provider advised you that there would not be a 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 a $150 copayment for diagnostic radiology services, not including X-rays. You have been asked to pay a $150 copayment for the myocardial perfusion imaging. Myocardial perfusion imaging 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 myocardial perfusion imaging provided on August 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 5, 2021, to August 9, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think it is fair to be charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.

You have been asked to pay a $325 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $1,300 ($325 x 4 days = $1,300). The correct copayment has been applied to the inpatient care that was provided. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 5, 2021, to August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of mobile x-ray equipment and personnel provided on July 23, 2021.

You asked the Plan to pay for the mobile x-ray transportation services. You say that this is a medically necessary service and should be reimbursed. The Plan denied your request. The Plan says this is not billed with a valid POS code.

The Plan must follow Medicare rules. Medicare rules say that POS code 31 is used for enrollees in a Part A covered SNF stay. For Part A SNF residents, the transportation of the mobile radiology equipment would be included in the SNF's payment rate. 

In this case, the rendered services are not payable with the POS code reported. Therefore, we decided that the Plan does not have to pay for the transportation of mobile x-ray equipment and personnel provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation care provided from August 18, 2021, to August 19, 2021.
You asked the Plan to waive the copayment for the hospital observation care. You say that you feel that you should not be responsible for the copayment since the stay was unplanned. 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 $200 copayment for hospital observation services. You have been asked to pay a $200 copayment for the hospital observation care. Hospital observation care falls within the Outpatient Hospital Observation 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 hospital observation care provided from August 18, 2021, to August 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the somatosensory testing (95927 and 95938) and continuous intraoperative neurophysiology monitoring (95940) provided on June 11, 2021.

You asked the Plan to pay for the somatosensory testing and continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration because payment should be made to this provider and not the facility. The Plan denied your request. The Plan says payment for these services is the responsibility of the facility.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT codes 95940, 95938 and 95927 are not supported in the record. Specifically, the record indicates that this mobile unit was serving a facility with its own valid POS code. Payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the somatosensory testing and continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for the somatosensory testing (95927 and 95938) and continuous intraoperative neurophysiology monitoring (95940) provided on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (84443, 36415, 80053, 80061) provided on September 28, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be covered as you have never had a copayment for these services before. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient hospital services. You have been asked to pay a $38.13 copayment for laboratory services, which is less than the $40 stated in the Plans contract. The record indicates that these services were performed in an outpatient setting. Laboratory services falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services (84443, 36415, 80053, 80061) provided on September 28, 2021.