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

We decided that the Plan does not have to pay for the surgery services provided by an out-of-network provider on December 15, 2020.

You asked the Plan to pay for the surgery services. You say that the plan information was not provided at the time of service and you were not able to obtain authorization. You say that the services were medically necessary and the account should have been paid in full. The Plan denied your request. The Plan says the surgery was performed at a non-participating facility and prior authorization was not requested. 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 surgery services provided by an out-of-network provider on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intravenous moderate (conscious) sedation/analgesia-first 15 minutes (D9239).

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.

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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an intravenous moderate (conscious) sedation/analgesia-first 15 minutes (D9239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a finger orthosis (L3933-LT) provided December 11, 2020.

You asked the Plan to pay for the orthosis. You say that the provider said that the orthotic is considered a
personal purchase and $808.50 is the cost. You would never have agreed to anything like this. You cannot
afford it. The orthotic was needed as part of your therapy. The Plan denied your request. The Plan says this is a
duplicate of a charge considered on a previous claim. The provider has previously billed code L3933-LT for
date of service 10/29/20, which is within the previous 5 years.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.

The file shows that you had L3933-LT at the time the orthosis was received. L3933-LT serves the same
purpose as the orthosis for date of service 10/29/20. Therefore, we decided that the Plan does not have to pay
for a finger orthosis (L3933-LT) provided December 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation and setup of x-ray equipment provided on
November 20, 2020.

You asked the Plan to pay for transportation of portable x-ray equipment and personnel to home or nursing
home, per trip to facility or location, more than one patient seen (R0075) and set-up portable x-ray equipment
(Q0092). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the member
was in a Skilled Nursing facility setting for November 20, 2020; therefore, we find the Medicare rule for
payment of this claim has not been met.

The Plan must follow Medicare rules. Medicare rules say as a general policy, the Place of Service code
assigned by the physician/practitioner for the Professional Component of a diagnostic service shall be the
setting in which the beneficiary received the Technical Component service.

Place of service is 31, Skilled Nursing Facility. We find that the payment is included in the SNF PPS. Based on
this information, we decided that Medicare rules for coverage of transportation of portable x-ray equipment and
personnel to home or nursing home, per trip to facility or location, more than one patient seen (R0075) and setup
portable x-ray equipment (Q0092) have not been met. Therefore, we decided that the Plan does not have to
pay for transportation and setup of x-ray equipment provided on November 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional PT visits.

You asked the Plan to pre-approve additional PT visits. You say that you have a diagnosis of rheumatoid arthritis and your condition warrants continuous PT. The Plan denied your request. The Plan says that you will no longer meet medical necessity criteria for continuation of rehabilitative outpatient physical therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 six (6) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been authorized for six (6) more sessions to ensure competence in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 23, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acupuncture treatment (97810, 97811)
provided on January 5, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

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 each additional acupuncture service.

You have been asked to pay a $15 copayment for the acupuncture treatment provided. 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 acupuncture treatment (97810, 97811) provided on January 5,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1833) suspension sleeve (L2397) shoulder elbow wrist hand orthosis (L3960) provided October 20, 2020.

You asked the Plan to pre-approve the orthoses. You say that the doctor who signed it has been treating you for at least 20 years and the problems have been examined multiple times. The Plan denied your request. The Plan says there is no claim on file for a provider that would have requested this DME, or the claim on file where this this equipment would have been requested is for a provider exam that was not conducted in-person.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthoses provided. There is no evidence of an established relationship between the enrollee and the ordering physician. There are no claims on file with the ordering physician listed in the enrollee's claims history from 2019 to present. There were no services found for the enrollee billed on the service date. The enrollee did not receive a video or telephonic visit by the ordering physician to warrant the codes billed. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1833) suspension sleeve (L2397) shoulder elbow wrist hand orthosis (L3960) provided October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 26, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because your husband was told that you would only owe a $180 copayment. 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 $300 copayment for advanced imaging services for outpatient hospital services. You have been asked to pay the allowed amount of $168.60, which is less than the $300 copayment for a CT scan. A CT scan falls within the outpatient hospital 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 a CT scan provided on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an inpatient hospital stay provided from January 15, 2021, to January 18, 2021.

You asked the Plan to waive the co-payment for an inpatient hospital stay. You say that you were not charged for a previous inpatient hospital stay and disagree with the charges. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 co-payment for days 1-5 for inpatient hospital care.

You had an inpatient hospital stay from January 15, 2021, to January 18, 2021. Therefore, you are responsible to pay a $150 co-payment for days 1-5 (January 15, 2021, to January 17, 2021). The total amount you owe is: $150 (co-payment) x 3 (inpatient days) = $450.

You have been asked to pay the total co-payment amount of $450 for an inpatient hospital stay. An inpatient hospital stay 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 co-payment for an inpatient hospital stay provided from January 15, 2021, to January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction provided on December 16, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction. You say that you were not advised that the treating provider did not accept Medicare. The Plan denied your request. The Plan says the treating provider opted out of the Medicare program effective March 22, 2018, to March 22, 2022. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic x-ray, and extraction provided on December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The documentation does not support that the requested LTACH services are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0230, D0220).

You asked the Plan to pay for intraoral periapical radiographic images. You say that you told the provider that these services would not be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 intraoral periapical radiographic images (D0230, D0220).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says based on the medical records received, the member does not meet the criteria for a skilled nursing facility admission.
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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to maintain function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is limited at this time due to her non-weight bearing status and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transportation service (A0427) provided on December 10, 2020.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co-payment per one-way trip for emergency ambulance services and non-emergency ambulance services provided.

You have been asked to pay a $300 co-payment for the one-way ambulance trip provided. 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 co-payment for the ambulance transportation service (A0427) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on December 22, 2020.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says Original
Medicare does not cover eye refractions for eyeglasses or contact lenses.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to
pay for an eye refraction provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and periodontal maintenance (D4910) provided on December 15, 2020.
You asked the Plan to pay for a comprehensive oral evaluation, and periodontal maintenance. You say that you were not aware that your annual maximum limit was reached, and you needed to wait for the new year for the services to be covered. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum had already been met before this date.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and periodontal maintenance have not been met. Specifically, the
record shows that you had exhausted your dental benefit maximum prior to this date of service. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and periodontal maintenance (D4910) provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this processed as in-network. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on December 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites provided on January 18, 2021.
You asked the Plan to pay for the resin-based composites. You say that you feel these services should be covered. The Plan denied your request. The Plan says these services 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 three resin-based composites provided on January 18, 2021.