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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2021, to January 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the SNF services. You say that the services provided were medically necessary. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says non-participating providers are required to obtain authorization for SNF admission. The Plan also says that service request for services that were already performed are not covered by the Plan.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 1, 2021, to January 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mouth guard to prevent teeth grinding (D9944).
You asked the Plan to pre-approve a mouth guard. You say that this service is medically necessary and was recommended by your dentist. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a mouth guard to prevent teeth grinding (D9944).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you are medically stable for discharge from the hospital. You have no worsening of any chronic medical problems. You have no skilled nursing needs. You have skilled therapy needs, but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve steroid injections (64484, 64483) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says there are 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve steroid injections (64484, 64483) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88360, 88365, 88307, 88342) provided May 26, 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 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. 

We find that CPT codes 88360, 88365, 88307, & 88342 are not supported in the medical record. Specifically, the claim form shows an outpatient place of service, however the records show the enrollee was an inpatient at the time services were provided. 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 (88360, 88365, 88307, 88342) provided May 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular stress test (93017) and echocardiology (93306) provided on July 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cardiovascular stress test and echocardiology. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says there is no authorization on file.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the cardiovascular stress test (93017) and echocardiology (93306) provided on July 19, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing service (G0480) rendered by the out-of-network (OON) provider on August 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the drug testing service (G0480) rendered by the out-of-network (OON) provider on August 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck (76536) provided on July 27, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not told you would owe a copayment for the ultrasound beforehand, and you feel the Plan should pay more for these services. 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 $100 copayment for diagnostic procedures and tests, including ultrasounds. You have been asked to pay a $100 copayment for the ultrasound. An ultrasound falls within the diagnostic procedures and tests, including ultrasounds 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 ultrasound of the head and neck (76536) provided on July 27, 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 December 14, 2019 to December 18, 2019.
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 payment of DRG 682 remains not supported, as the review of the records supports DRG 282. 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 682 (RENAL FAILURE 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 a principal diagnosis code of N17.9 (acute kidney failure, unspecified) was reported by the hospital. According to coding guidelines and clinics, this code did not qualify for reporting. The facility agrees with the removal of principal diagnosis code N17.9 and is requesting secondary diagnosis code assignment I21.A1 (myocardial infarction type 2) be sequenced as the new 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 hospital services provided to the enrollee from December 14, 2019 to December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, 64628, C9752).
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is experimental and non-covered.
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 pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, 64628, C9752).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided to the enrollee on November 18, 2020.

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 Current Procedural Terminology (CPT) code 99291 (1 Unit) remains 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. 

In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes." 

We find that CPT code 99291 is not supported in the medical record. Specifically, there was no documentation showing the time spent providing the critical care services. This documentation is necessary as CPT 99291 is a time-based code. 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 critical care services provided to the enrollee on November 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on March 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you feel that the copayment should only be $50. 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 $110 copayment for diagnostic radiology services, including ultrasounds. You have been asked to pay $65.61, which is less than the $110 copayment for the ultrasound. Please note that an ultrasound is considered a radiological service, not a regular diagnostic test. The ultrasound falls within the
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound of the breast provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services provided July 9, 2021, to July 13, 2021.
You asked the Plan to waive the copayment for the inpatient admission and services. You say that you expected to have an outpatient stay and this cost is too high. The Plan denied your request. The Plan says the copayment 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 $275 copayment per day for days 1 through 6 per benefit period for inpatient hospital care. You have been asked to pay a total of $1,100 ($275 copayment x 4 days = $1,100) for the inpatient admission
and services. This service falls within the Inpatient hospital 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 the inpatient admission and services provided July 9, 2021, to July 13, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided on August 3, 2021.

You asked the Plan to waive the copayment for emergency room services. You say that you feel you should not pay this charge because you had to wait to see the doctor. The Plan denied your request. The Plan says the cost-sharing applied 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 $90 copayment for emergency care visits.

You have been asked to pay a $90 copayment for emergency room services. Emergency room services fall 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 emergency room services provided on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Codeine Sulfate.

You asked the Plan to pre-approve Codeine Sulfate. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Codeine Sulfate is not covered under your Medicare Part B benefit.

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 Codeine Sulfate.

Benefits for Codeine Sulfate 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 waive the copayments for podiatry services and does not have to waive the coinsurance for medical supplies provided from August 19, 2021, to October 15, 2021.
You asked the Plan to waive the copayments for podiatry services and to waive the coinsurance for medical supplies. You say that you were told by the provider that the services would fall under a global period and you would not be charged. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for podiatry services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for medical supplies. You received podiatry services from August 19, 2021, to October 15, 2021, for a total of 7 visits. Therefore, you are responsible to pay a $15 copayment per each visit. The total amount you owe for podiatry services is: $15 (copayment) x 7 (podiatry services) = $105. You received medical supplies from August 19, 2021, to October 15, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount You Owe
9/3/2021
Medical Supplies
$971.89
$209.38
9/17/2021
Medical Supplies
$971.89
$209.38
9/24/2021
Medical Supplies
$971.89
$209.38
10/8/2021
Medical Supplies
$973.59
$209.72
10/15/2021
Medical Supplies
$973.59
$209.72
The total amount you owe for medical supplies is: $1,047.58.
The total amount you owe is: $1,152.58. You have been asked to pay the total amount of $1,152.58 for podiatry services and medical supplies. Podiatry services fall within the podiatry services benefit category. Medical supplies 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 copayments for podiatry services and does not have to waive the coinsurance for medical supplies provided from August 19, 2021, to October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.
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 pre-approve the radiofrequency ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure remains investigational because of the wide variation in efficacy. More research is needed to show safety and efficacy. 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 radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for SelectMDx testing provided on February 16, 2021.

You asked the Plan to pay for genetic testing. You say that this test was requested directly by the treating physician who makes the professional determination of diagnosis and medical necessity to successfully treat the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the clinical utility and analytical validity are not established for this test.

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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

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 specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for SelectMDx testing provided on February 16, 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.