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

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with polyp removal you had on June 28, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy with polyp removal. You say that you cannot afford this copayment. 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 $250 copayment for outpatient surgery.   You have been asked to pay a $250 copayment for the diagnostic colonoscopy with polyp removal. The Plan contract says that if you have polyps removed during a colonoscopy, it is considered diagnostic.  Diagnostic colonoscopies are subject to the outpatient surgery cost sharing.  You had a polyp removed during this colonoscopy, so you were charged the outpatient surgery copayment. 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 diagnostic colonoscopy with polyp removal you had on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87631, 87640, 87798) rendered by the out-of-network (OON) provider on January 4, 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 (87486, 87496, 87498, 87532, 87541, 87581, 87631, 87640, 87798) rendered by the out-of-network (OON) provider on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit you had with a pulmonology specialist on July 28, 2021.  You asked the Plan to waive the copayment for the pulmonology visit. You say that you did not see the physician on this date of service. The Plan denied your request. The Plan says you were seen by a nurse practitioner in the specialist's office under the direction of the physician.  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 $40 copayment for physician/practitioner services in a specialist's office.   You have been asked to pay a $40 copayment for the pulmonology visit. This copayment applies to all physician and practitioner services in a specialist office. 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 office visit you had with a pulmonology specialist on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on August 17, 2020.  You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  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 documentation submitted shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccines provided on February 28, 2020, and May 19, 2020.  You asked the Plan to pay for the shingles vaccines. You say that you were told that the Plan would pay for these services with 5% cost share plus an office visit charge. The Plan denied your request. The Plan says this vaccines is only covered by the Part D program. Coverage must be requested from the Part D plan.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccines. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccines. Therefore, we decided that the Plan does not have to pay for the shingles vaccines provided on February 28, 2020, and May 19, 2020.   Benefits for the shingles vaccines may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), surgical extraction (D7210), unspecified preventive service (D1999), and gingival irrigation (D4921) provided on May 10, 2021.  You asked the Plan to pay for the dental services. You say that you had severe pain which made it impossible for you to eat. You say that you were given 4 in network providers that were given to you by a plan representative. You say that 3 of them were no longer in network and the other could not get you in for months. You say that you had no other choice but to go to the emergency dental clinic for your pain. The Plan denied your request. The Plan says the provider in this case does not participate with the Plan. The Plan also says that dental services must be provided by a participating general dentist.  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, dental service received by a non-participating general dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), surgical extraction (D7210), unspecified preventive service (D1999), and gingival irrigation (D4921) provided on May 10, 2021.
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 not at your baseline and need SNF services prior to returning home. The Plan denied your request. The Plan says SNF care is not medically necessary.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had clear lungs. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at maximal assist level with functional mobility and required varying assist with activities of daily living. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office consultation. You say that these services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide for the enrollee's medical needs.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-network (OON) provider.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services (99053) provided on July 31, 2021.  You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the medical services (99053) provided on July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the basic metabolic panel and hepatitis C antibody testing provided on July 9, 2021.  You asked the Plan to pay for the rendered testing. You say that these services are covered by Medicare and should be paid. The Plan denied your request. The Plan says despite several attempts to obtain additional information, no medical records or copy of a physician order were submitted.    The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by a physician and such order must be documented and submitted upon request. Sufficient information must be provided to support that coverage criteria are met.   In this case, the Plan documented multiple faxes requesting the visit note from the ordering provider, as well as the physician order and laboratory results. None of these items were submitted. Therefore, we decided that the Plan does not have to pay for the basic metabolic panel and hepatitis C antibody testing provided on  July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient hospital facility on July 12, 2021.  You asked the Plan to waive the copayment for the lab services. You say that you don't have a freestanding lab within 20 miles of your home, so you don't think you should have to pay the copayment. 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 $25 copayment for lab services performed in an outpatient hospital facility.   You have been asked to pay a $25 copayment for the lab services. This copayment applies regardless of the reason why you had to use the hospital facility. 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 lab services you received at an outpatient hospital facility on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87631, 87640, 87798) rendered by the out-of-network (OON) provider on May 10, 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 (87486, 87496, 87498, 87532, 87541, 87581, 87631, 87640, 87798) rendered by the out-of-network (OON) provider on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for specialist office visits (99214) rendered from June 1, 2020, to July 1, 2020.  You asked the Plan to reduce the copayments for specialist office visits. You say that you saw the nurse practitioner, not the provider. You also say that you should only have a $5 copayment. The Plan denied your request. The Plan says you were charged the correct copayment 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 $40 copayment for each specialist visit for Medicare-covered benefits.   You have been asked to pay a $40 copayment per visit for 2 specialist office visits, which is a total of $80 ($40 x 2 = $80). Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category. The record shows you had an office visit in a specialist's office for pain management. 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 reduce the copayments for specialist office visits (99214) rendered from June 1, 2020, to July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (80307, G0483) rendered by the out-of-network (OON) provider on March 30, 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 the 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 drug testing (80307, G0483) rendered by the out-of-network (OON) provider on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).  You asked the Plan to pre-approve an ultrasonic osteogenesis stimulator. You say that the requested device is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that the criteria listed in Medicare rules section must be met before coverage can be approved.  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 ultrasonic osteogenesis stimulator. Our reviewer says that the requested services are not medically reasonable and necessary based on the Medicare coverage criteria. Our physician reviewer found in this case, not enough time has passed since the fracture to establish the diagnosis of nonunion. For the requested osteogenesis stimulator, nine months is needed before the requested item can be considered for coverage.  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 ultrasonic osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator (E0760).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you require physical therapy and occupational therapy services. You will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.  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: 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 SNF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee does not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and IV antibiotics. The enrollee had stable vital signs and underwent incision and drainage of the left shoulder with removal of place and screw fixation of proximal humerus. The enrollee was treated for pain. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.