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

We decided that the Plan does not have to pay for the rest home visit (99336) provided on January 20, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like reconsideration because the provider is contracted with the member's facility. The Plan denied your request. The Plan says the out-of-network services were not urgent, emergent or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit (99336) provided on January 20, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 13, 2020.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy. 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 physical therapy provided on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), periapical first radiographic image (D0220), and unspecified preventative procedure, by report (D1999) provided December 18, 2020.
You asked the Plan to pay for the limited oral evaluation, periapical x-ray and unspecified preventative procedure. You say that the services were medically necessary to avoid infection. The Plan denied your request. The Plan says the services are not covered under 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 pay for the limited oral evaluation - problem focused (D0140), periapical first radiographic image (D0220), and unspecified preventative procedure, by report (D1999) provided December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardio panel provided on November 16, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

In this case, the records do not show that the results of the testing would be used in conjunction for a specific treatment strategy. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardio panel provided on November 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing care in the home; per hour, provided from October 28, 2020, to November 20, 2020.

You asked the Plan to pay for the home health aide services. You say that you were in the hospital and discharged to receive physical therapy, occupational therapy, and personal hygiene assistance during the recuperation period. You say that the company used for the therapy services did not handle personal care. You also say that you have hired a local agency. The Plan denied your request. The Plan says a provider must be eligible to participate in Medicare to receive payment. The Plan says that the provider in this case is out of network and is not Medicare certified.

The Plan must follow Medicare rules. Medicare rules say that providers that are not enrolled in Medicare, are not payable by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing care in the home; per hour, provided from October 28, 2020, to November 20, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely be received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID 19 pneumonia and respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 9, 2020, to January 17, 2021.

You asked the Plan to waive the copayment for specialist services. You say that you do not agree with these charges. 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 $25 copayment for physician/practitioner services/in-network/specialist. 

You have been asked to pay a $25 copayment for specialist services. The total amount you are being asked to pay is $250 ($25 x 10 visits = $250). Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on March 9, 2020, to January 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 15004) provided to the enrollee on October 20, 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 the records do not support the service 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. 

In this case, the CPT Code Manual definition of code 15004 is "surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar(including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; for the first 100sq cm or 1% of body area of infants and children." 

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 that in this case, the operative note describes the creation of an advancement flap. The operative note does not describe a preparation of recipient site by excision, but rather debridement. The elements of CPT code 15004 are not satisfied. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 15004) provided to the enrollee on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for immunohistochemistry (88342) and morphometric analysis (88360) provided on October 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this service should be considered urgent or emergent due to the viability of the specimen. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for immunohistochemistry (88342) and morphometric analysis (88360) provided on October 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and annual wellness exam provided on July 14, 2020 by an out of network provider.

You asked the Plan to pay for the office visit and annual wellness exam. You say that the services were medically necessary. The Plan denied your request. The Plan says you did not request 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 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 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 office visit and annual wellness exam provided on July 14, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on November
13, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you needed to have blood
work and there is no lab close to your town. You say that you should not be billed. The Plan denied your
request. The Plan says the copayment 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 $35
copayment for lab services at an outpatient hospital.
You have been asked to pay a $35 copayment for laboratory services. Laboratory services fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for laboratory services provided on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320) for tooth # 4 provided on November 25, 2020.
You asked the Plan to pay for the dental service. You say that you had a tooth that was crumbling. You say that you were in pain. You say that the dentist did a thorough examination and explained what needed to be done. You say that you could not go for a second opinion because you were in pain. You also say that you could not check to see if the service was covered. The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan also says that any services not listed are not covered.
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 pay for the root canal (D3320) for tooth # 4 provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve provided on October 13, 2020.

You asked the Plan to pay for knee orthotics. You say that you are appealing with supporting records which will be sufficient to allow the Plan to pay this claim. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the enrollee did not receive a video or telephonic visit by the ordering physician to warrant the codes billed.

The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter is required within the 6 months prior to prescribing an item. 

We looked at the file and Medicare rules. The documentation does not include a face-to-face encounter within the 6 months prior to this item being prescribed, and the records submitted do not show that this was an approved use of telehealth examination for the purposes of ordering DMEPOS items. Based on this information, we decided that Medicare rules for coverage of knee orthotics have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve provided on October 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 15, 2020.

You asked the Plan to pay for the ambulance services. You say that you are requesting the enrollee to be
responsible for this service. The Plan denied your request. The Plan says these services are not a covered
benefit.

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 May 15, 2020. 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 services provided on May 15,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on October 23, 2020, to November 23, 2020.

You asked the Plan to waive the coinsurance for a commode. You say that you will not pay this. You say that you could not even use the commode because it was too low. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment/in-network. 

You have been asked to pay a 20% coinsurance of the allowed amount for a commode. The total allowed amount is $32.26. The total amount you are being asked to pay is $6.46 ($32.26 x 20% = $6.46). A commode falls within the durable medical equipment/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 coinsurance for durable medical equipment provided by a participating provider on October 23, 2020, to November 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from March 1, 2020, to March 25, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you were not advised that you would be charged for any days in the SNF. You also say that you are not responsible for the $1,280 you have been charged. 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 a $0 copayment per day for days 1 to 20 and a $160 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This stay lasted 24 days, which were days 5 to 28 of the benefit period, resulting in a total copayment amount of $1,280. You have been asked to pay a $0 copayment per day for days 1 to 20 and a $160 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 SNF care provided from March 1, 2020, to March 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network dermatologist.
You asked the Plan to pre-approve these services. You say that the enrollee needs a Mohs surgeon. The Plan denied your request. The Plan says the services are available from network providers.
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. The Plan confirmed that the network providers can perform Mohs surgery. 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 a referral to an out-of-network dermatologist.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room visit provided on October 7, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the emergency room copayment. You state you went for pretesting for knee surgery and due to heart issues, you were sent to the emergency room. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you went to the emergency room on October 7, 2020. You were asked to pay a $90 copayment for the emergency care. The health plan contract says that enrollees must pay a $90 copay for each Medicare-covered emergency room visit. 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 visit provided on October 7, 2020.