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

We decided that the Plan does not have to pay for routine transportation provided from April 6, 2021, through
April 19, 2021.
You asked the Plan to pay for routine transportation. You say that the Plan's provider was only able to provide
you transportation to your doctor's visit, but you would have no way back home. The Plan denied your request.
The Plan says the transportation benefit is covered only when provided by the Plan's transportation vendor.
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 routine transportation when provided by the Plan's transportation vendor.
We looked at your request, the records in the case file, and the rules. The file shows that the routine
transportation was not provided by the Plan's transportation vendor. Based on this information, we decided that
the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan
does not have to pay for routine transportation provided from April 6, 2021, through April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate or equal lenses (V2784) provided on March 17, 2021.

You asked the Plan to pay for polycarbonate lenses. You say that the items at issue are a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because the items at issue are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for polycarbonate or equal lenses (V2784) provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home ventilator you received on May
24, 2021.

You asked the Plan to waive the coinsurance for the home ventilator. You say that you have never had to pay
for your ventilator before and you cannot afford this cost sharing. The Plan denied your request. The Plan says
you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for durable medical equipment.

You have been asked to pay 20% coinsurance for the home ventilator. The home ventilator falls within the
durable medical equipment 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 the home ventilator you received on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 15, 2021 to April 8, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting an appeal for the denial of an inpatient stay, based on clinical documentation provided. The Plan denied your request. The Plan says that prior approval was not obtained for the inpatient admission.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found at the time of inpatient admission, the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 15, 2021 to April 8, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit services beyond the scope of an annual wellness visit represented by code 99214 provided on March 26, 2021.

You asked the Plan to waive the copayment for the office visit services (99214). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received office visit services beyond the scope of your annual wellness visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $5 copayment for Physician/Practitioners services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received office visit services beyond the scope of your annual wellness visit on March 26, 2021. You have been asked to pay a $5 copayment for the office visit services (99214). The office visit services (99214) fall within the Physician/Practitioners 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 the office visit services beyond the scope of an annual wellness visit represented by code 99214 provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services (99349, 11045, 11042) provided on April 28, 2021.

You asked the Plan to pay for the wound care services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 services at issue in this appeal. The Plan did not pre-approve the service 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 wound care services (99349, 11045, 11042) provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2020.
You asked the Plan to pay for the laboratory services. 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. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 31. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Northera.

You asked the Plan to pre-approve Northera. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Northera.

Benefits for Northera 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on May 18, 2021.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 services at issue in this appeal. The Plan did not pre-approve the service 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 an office visit (99203) provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the imaging and injection services rendered on March 20, 2020.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for chemotherapy and all other drugs covered under Medicare Part B and a $75 copayment for diagnostic procedures and tests performed by a provider other than your primary care physician.
Review of the file shows that you received an injection of regadenoson on March 20, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $48.37. These services fall within the
chemotherapy and all other drugs covered under Medicare Part B benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received a transthoracic echocardiography (TTE) on March 20, 2020. You have been asked to pay a $75 copayment for these services. These services fall within the diagnostic procedures and tests performed by a provider other than your primary care physician benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received myocardial perfusion imaging (MPI) on March 20, 2020. Per the contract with the Plan, there is a $75 copayment for diagnostic procedures and tests performed by a provider other than your primary care physician. However, the Plan has asked you to pay a $25 copayment for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $148.37. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the imaging and injection services rendered on March 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo.

You asked the Plan to pre-approve Livalo. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.

Benefits for Livalo 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on November 20, 2019.

You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that this service was performed by an occupational therapist in a home health or hospice setting. There is a more appropriate code to be billed for these services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on November 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on
April 10, 2021.
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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 99223 is initial hospital care, per day, for the evaluation
and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor
or unit.
We find that CPT code 99223 is not supported in the medical record. Specifically, the documentation does not
support a medical decision making of high complexity for this date of service. Based on this information, we
decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we
decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on April
10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on May 21, 2021.

You asked the Plan to waive the copayment for primary care visit. You say that you should not have a copayment for your annual wellness visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $15 copayment for primary care visit. This visit addressed non-routine diagnoses that go beyond the annual wellness visit, so an office visit with copayment was billed in addition to the annual wellness visit.

You have been asked to pay $15 copayment for primary care visit. Primary care visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 primary care office visit provided on May 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided by a clinical psychologist on April 14, 2021.

You asked the Plan to pay for the services. You say that the physician provided these services in good faith. The Plan denied your request. The Plan says there was no documentation of a consultation with the attending or primary care physician in the medical record.

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 90832 is "Psychotherapy, 30 minutes with patient." 

We find that CPT code 90832 is not supported in the medical record. Specifically, the record shows that the services were provided by a Clinical Psychologist without consultation from the enrollee's Primary Care Physician. 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 outpatient mental health services provided by a clinical psychologist on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for coronavirus testing (U0002) provided on May 12, 2021.

You asked the Plan to pay for coronavirus testing. You say that this is a payable code. The Plan denied your request. The Plan says this is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT code U0002 is not supported in the medical record. Specifically, no medical records have been submitted to verify this service was performed. Based on this information, we decided that Medicare rules for coverage of coronavirus testing have not been met. Therefore, we decided that the Plan does not have to pay for coronavirus testing (U0002) provided on May 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided from March 19, 2021, to April 8, 2021.
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that this is an appropriate code due to coronavirus. The Plan denied your request. The Plan says this code is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Code 99072 has a status code of B, meaning it is not separately payable. Based on this information, we decided that Medicare rules for coverage of additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided from March 19, 2021, to April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a collagenase injection (J0775) provided on November 24, 2020, to December 2, 2020.

You asked the Plan to waive the coinsurance for injections. You say that you asked your provider if there was an additional charge besides the $40 at the time of the visits and was advised that it was covered. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

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% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for each injection. The records show you had an injection on two (2) office visits with a specialist. The allowed amount of each claim is $1,676.48, resulting in a coinsurance obligation of $335.30 for each visit. The EOC confirms that 20% is the required coinsurance for this service. Injections fall within the Medicare Part B prescription drugs 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 collagenase injection (J0775) provided on November 24, 2020, to December 2, 2020.