Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam (92004) provided on
October 19, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was supposed to be a regular
check-up for your eyes, and you were told afterward to return for additional glaucoma testing. You were told
upon arrival that you would not owe a copayment for this service and feel you have been deceived. The Plan
denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in
accordance with your contract.
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 $30
copayment for Medicare-covered vision services provided in a specialist's office.
You have been asked to pay a $30 copayment for the eye exam. The eye exam in question was billed with
medical diagnoses and was submitted as a medical eye exam rather than a screening or routine exam. Please
note that if symptoms are present at the start of an exam or are found during the course of a screening, the
test/exam becomes diagnostic in nature. 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 medical
eye exam (92004) provided on October 19, 2021.
Your complaint about potential misinformation from a Plan-contracted provider 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the UV lens (V2755) and color tint (V2745) provided for the eyeglasses on September 3, 2021.
You asked the Plan to pay for the lens enhancements. You say that these services should be paid. The Plan denied your request. The Plan says lens enhancements are not covered by the enrollee's vision benefit.
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. Though the Plan offers a vision benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the UV lens (V2755) and color tint (V2745) provided for the eyeglasses on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on September 23, 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 out of network medical services provided to the enrollee on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 15, 2021, to May 25, 2021.
You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request. The Plan says the provider has reported inpatient hospital services with the incorrect DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC). 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the records were inconsistent and incomplete to confirm mental status changes and hemodynamic instability to support a principle diagnosis of sepsis. Despite leukocytosis, an elevated serum creatinine level and tachycardia at presentation the totality of the medical records presented is more consistent with code N39.0 (Urinary tract infection, site not specified) and DRG 689. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 15, 2021, to May 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a specialist office visit provided on November 9, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you were charged to see both your doctor and a nurse during the same office visit. You say that you should not have been separately charged to see the nurse. The Plan denied your request. The Plan says that the copayment applied was correct.
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 did not provide evidence that a claim was not separately submitted for the nurse practitioner seen during your specialist office visit with your physician. Therefore, we decided that the Plan has to waive the copayment for a specialist office visit provided on November 9, 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: 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 is on a ventilator to help breathing, but
only one rehabilitation facility can take him. The Plan denied your request. The Plan says the denial of
authorization for IRF service is correct.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing
facility.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing provided to the enrollee on June 7, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing provided to the enrollee on June 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.
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 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 you appear to have improved with therapy but continues to have some difficulty descending stairs and with limping after prolonged walking. Further skilled therapy beyond the now 60 total approved visits at this point do not appear to be medically necessary to achieve improvement in your symptoms and functional status. Further utilization of the home exercise program appears appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are
not met.
The Plan follows Medicare rules. Medicare rules say that NGS is covered for the indications established in the
applicable NCD.
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 pay for the testing. Our reviewer says that the
requested testing is not medically reasonable and necessary. Our physician reviewer found that the provided
records do not document either recurrent, relapsed, refractory, metastatic or advanced stage III or IV cancer;
the enrollee has not been previously tested with the same test using NGS for the same cancer genetic content,
and the enrollee has decided to seek further cancer treatment (e.g., therapeutic chemotherapy) as required by
the National Coverage Determination.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the genetic testing provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the abdomen (74018) provided on September 29,
2021.
You asked the Plan to pay for an X-ray of the abdomen. You say that the service at issue was a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met
because the service at issue was not billed according to Medicare 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, we have confirmed that code 74018
is a column II code to column I code 74420. 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 an X-ray of the abdomen (74018) provided on September 29,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the chest (71046) provided on August 6,
2021.
You asked the Plan to pay for the x-ray. You say that this denial is incorrect, and this claim was billed properly
as this is the setting where the service took place. The Plan denied your request. The Plan says this claim was
billed with an inappropriate place of service (POS) code. Documentation shows that the enrollee was inpatient
status during this date of service, and therefore this service must be billed with the inpatient hospital POS code
regardless of the setting where the enrollee actually received the encounter.
The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing
services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital Place of
Service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the x-ray have not been met. Specifically, the submitted claim was billed with POS code 22 for
On-Campus Outpatient Hospital. The documentation shows that the enrollee was registered as inpatient from
August 4, 2021, to August 19, 2021, and was therefore inpatient on the date in question. This means that the
claim was not billed with the appropriate POS code. Therefore, we decided that the Plan does not have to pay
for the x-ray exam of the chest (71046) provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gammaplex injections (J1557) provided from September
22, 2021, to October 13, 2021.
You asked the Plan to pay for the Gammaplex injections (J1557). You say that the Gammaplex injections
provided from September 22, 2021, to October 13, 2021 were medically necessary. The Plan denied your
request. The Plan says the enrollee did not meet criteria for the Gammaplex injections provided from
September 22, 2021, to October 13, 2021.
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 pay for the Gammaplex injections (J1557). Our
reviewer says that the enrollee did not meet criteria for the Gammaplex injections provided from September 22,
2021, to October 13, 2021. Our physician reviewer found the review indicates that the enrollee was with a
history of Fibromyalgia, IgM deficiency, Gastroparesis, chronic obstructive pulmonary disease (COPD) and
dysphagia. Per the documentation she received Gammaplex injections from September 22, 2021, to October
13, 2021. The injections were not for a covered condition per the criteria. The review has determined that the
enrollee did not meet the above LCD criteria for the Gammaplex injections provided from September 22, 2021,
to October 13, 2021.
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 Gammaplex injections (J1557) have not been met. Therefore, we decided
that the Plan does not have to pay for the Gammaplex injections (J1557) provided from September 22, 2021, to
October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from December 30, 2019, to January
21, 2020, and billed with DRG (diagnosis related group) 812.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your
request. The Plan says an itemized bill has not been received to support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 812, red blood cell disorders without major
complications or comorbidities. 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 pay for inpatient care.
Our reviewer says that the billed DRG is not supported. Our physician reviewer found the records show that the
enrollee was admitted for a right hemiglossectomy with a left radial forearm free flap and a left thigh split
thickness skin graft following a tracheostomy and bilateral neck dissections. The circumstances of inpatient
admission should always govern the selection of principal diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided from December 30, 2019, to January 21, 2020, and billed with DRG (diagnosis
related group) 812.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray examination of the cervical spine (72052) provided
on October 13, 2021.
You asked the Plan to pay for an X-ray examination of the cervical spine. You say that the service at issue was
a medical necessity for the enrollee. The Plan denied your request. The Plan says the service at issue was not
billed as required by Medicare 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, we have confirmed that code 72052
is a column II code to column I code 72082. 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 an X-ray examination of the cervical spine (72052) provided on
October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services at inpatient hospital services (99223,
99232, 99233) and a thrombectomy of arterial or venous graft (35876) provided on July 14, 2021, to July 17,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for physician services at inpatient hospital services and a thrombectomy of arterial
or venous graft. You say that you are appealing with supporting records to show this was medically necessary.
The Plan denied your request. The Plan says there are no records of a referral from the member's primary care
provider to the Plan prior to services being rendered, nor are there any records of a prior authorization being
obtained. The Plan also says that in-network providers are within the time and distance standards set forth by
Medicare. The Plan also says this provider is not a network provider.
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 physician services at inpatient hospital services
(99223, 99232, 99233) and a thrombectomy of arterial or venous graft (35876) provided on July 14, 2021, to
July 17, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 7,
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, we have confirmed that code 70544
is a column II code to column I code 70551. 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 imaging services provided to the enrollee on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73030) provided on November
12, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you
already pay your premium. 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 $20
copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $20 copayment for an x-ray. X-rays fall 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
an x-ray (73030) provided on November 12, 2021.