Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 31, 2021.

You asked the Plan to waive the copayment for the urgent care visit. You say that you do not remember seeing any doctor on that day. 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 $45 copayment for each visit to other providers for urgently needed services.

You have been asked to pay a $45 copayment for urgent care visit. The urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on July 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 3, 2021.
You asked the Plan to pay for the ambulance service. You say that the code billed in a valid code and should be paid. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since there was no transport provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tint photochromatic per lens and anti-reflective coating per lens provided on August 31, 2021.
You asked the Plan to pay for tint photochromatic per lens and anti-reflective coating per lens. You say that you could not read print and need the tint to help with the bright sun. The Plan denied your request. The Plan says additional lens options including, but not limited to, tinting, scratch coating, UV or anti-reflective coating are not covered.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that additional lens options including, but not limited to, tinting, scratch coating, UV or anti-reflective coating are not covered. Therefore, we decided that the Plan does not have to pay for tint photochromatic per lens and anti-reflective coating per lens provided on
August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on July 26, 2021.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are not
covered.
We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we
decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that
the Plan does not have to pay for CxBladder testing (0012M) provided on July 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on May 5, 2021.

You asked the Plan to pay for the services. You say that you would like this claim to be reprocessed. The Plan denied your request. The Plan says insufficient documentation has been submitted to corroborate the services.

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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 

We asked our coder 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 reviewer found the documentation describes that physical therapy services were provided in the enrollee's home. CPT 97110 is an incorrect procedure code to report for services performed in the home. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for services provided.

We looked at this coder's review, the file, and Medicare rules. 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 the therapeutic exercises (97110) provided on May 5, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on August 8, 2021.  

You asked the Plan to waive the copayment for the ER visit. You say that you would like the bill taken care of. 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 $120 copayment for each emergency room visit.   

You have been asked to pay $78.04, which is less than the $120 copayment for the ER visit. The ER visit falls within the Emergency Care 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 emergency room (ER) visit provided on August 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fillings for teeth # 5, 10, and 13 provided on September 7, 2021.  You asked the Plan to pay for the filling for tooth # 5. You say that you were not able to get into any of the in network dentists given to you by a plan representative. You say that you felt that your issue was an emergency. You say that you went to a dentist where you could get in. You also say that you were not informed there would be additional costs if you went to an out of network dentist. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that the frequency limits has been exceeded.  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 and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the fillings for teeth # 10 and 13 that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 5, 10, and 13 provided on September 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on September 20, 2021.  You asked the Plan to pay for the hot or cold pack therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 97010 has a status indicator of B.  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 CPT code 97010 is not supported in the record. Specifically, CPT code 97010 has a status indicator of B. This means that payment for CPT code 97010 is always bundled into the payment for another service. Based on this information, we decided that Medicare rules for coverage of the hot or cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography, neck (70549).  You asked the Plan to pay for the diagnostic service. You say that you are appealing the denied authorization of an MRA of the brain and neck. The MRI was approved but you need to be able to see a vascular malformation and the MRA would be better to see this than the approved MRI. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria.  The Plan must follow Medicare rules. Medicare rules say that MRA's are covered only when they are medically necessary.   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 diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case is noted to have a history more consistent with facial pain. There was no documentation that the enrollee has a conditions of the head and neck for which surgery is anticipated. In as much this service would not be considered to be reasonable and necessary.  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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography, neck (70549).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (38724, 60502, 83970, 88307, J0330, J0690, J1100, J2370, J2405, J2550, J3010) provided August 18, 2021.

You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 CPT codes 38724, 60502, 83970, 88307, J0330, J0690, J1100, J2370, J2405, J2550, & J3010 are not supported in the medical record. Specifically, the record shows these services were performed on the same date of service as an inpatient procedure and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (38724, 60502, 83970, 88307, J0330, J0690, J1100, J2370, J2405, J2550, J3010) provided August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided July 16, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says documentation does not support the billed services.
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 CPT code G0482 is not supported in the medical record. Specifically, the records show the specimen was obtained in the office setting (POS 11) while the claim states the place of service was a laboratory (POS 81). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face-down equipment provided to the enrollee from July 6, 2021, to July 12, 2021.
You asked the Plan to pay for the equipment. You say that this was needed following retina surgery. The Plan denied your request. The Plan says this is primarily not medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Our doctor found that based on the medical records provided, there is no documentation that this equipment provided to the enrollee meets Medicare criteria for coverage. The provided equipment is classified as a "precautionary device" by Medicare and is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for face-down equipment provided to the enrollee from July 6, 2021, to July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from October 21, 2019, to October 7, 2021.

You asked the Plan to pay for the dental services provided from October 5, 2020, to October 7, 2021. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to a provider that has opted out of Medicare.

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, payment cannot be made to providers that have opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided from October 21, 2019, to October 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on September 21, 2021, to December 7, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that you thought that your copayment amount would be $10 a session. 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 $30 copayment for outpatient rehabilitation services/in-network.
You have been asked to pay a $30 copayment for each physical therapy sessions. The total amount you are being asked to pay is $330 ($30 x 11 sessions = $330). Physical therapy falls within the outpatient rehabilitation services/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 physical therapy provided by a participating provider on September 21, 2021, to December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided to the enrollee on August 2, 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 despite multiple outreaches by the plan, the provider has not submitted any clinical records to support the medical necessity of the services.

The Plan must follow Medicare rules. Medicare rules say that providers must substantiate the need for payment for denied services. 

We looked at the file and Medicare Rules. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the billed services. Without the medical records, the billed services cannot be verified. Therefore, we decided that the Plan does not have to pay for pain management services provided to the enrollee on August 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided July 20, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance service. You say that you would like the copayment waived. The Plan denied your request. The Plan says the copyament 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 $300 copayment for each one-way Medicare-covered trip by ambulance.  You have been asked to pay a $300 copayment for the non-emergency ambulance service. The non-emergency ambulance service falls within the Ambulance 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 ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided July 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from February 8, 2019, to February 13, 2019.  You asked the Plan to pay for the services. You say that you want to appeal the overpayment. The Plan denied your request. The Plan says the correct assessment was not sent in to determine payment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code  is not supported in the medical record. Specifically, there is no evidence that the provider sent a valid Minimum Data Set (MDS) 5 day or Admission assessment. This is needed to determinate the applicable Resource Utilization Group (RUG) score. Without this specific information, a generic RUG score must be applied to determine payment. 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 skilled nursing facility (SNF) services provided to the enrollee from February 8, 2019, to February 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99202) provided July 16, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was billed with an invalid place of 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. In this case, the CPT Code Manual definition of code 99202 is Office or other outpatient visit for the evaluation and management of a new patient. We find that CPT code 99202 is not supported in the medical record. Specifically, the claim was billed with place of service 23 (emergency room). This place of service is not valid for the CPT code billed. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.
Therefore, we decided that the Plan does not have to pay for physician services (99202) provided July 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for SNF care have 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has no identifiable skilled nursing service needs. The enrollee does have identifiable skilled therapy service needs; however, the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15mg Xarelto tablets.
You asked the Plan to pre-approve the Xarelto tablets. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under Medicare Part B.
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 15mg Xarelto tablets.
Benefits for the Xarelto tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.