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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received March 31, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the copay should be waived because this was a medically necessary ambulance ride.The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $150 copayment for Ambulance Services. 

You have been asked to pay a $150 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0427, A0425) received March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on June 15, 2020.

You asked the Plan to pay for the nursing facility visit. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and the claim should be processed for payment at the maximum amount allowed. The Plan denied your request. The Plan says utilization of in-network providers is required unless the Plan pre-approves out-of-network services.

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 nursing facility visit provided by an out-of-network provider on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bariatric surgery consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the bariatric surgery consultation. You say that you would like reconsideration because the member would be better served by the requested provider due to their cardiomyopathy. The Plan denied your request. The Plan says bariatric surgery and any associated cardiovascular concerns can be addressed through the Plan's provider network.

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 provider at issue in this case is not a network provider with the Plan. 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 bariatric surgery consultation. Our reviewer says that the elements of the coverage criteria are not established.

Our physician reviewer found the enrollee has not been evaluated by the plan's in network Bariatric surgery program. The current documentation is insufficient to determine that the in network service providers would be unable to provide the requested service. 

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 bariatric surgery consultation have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. 

We found no exception that would require the Plan to pre-approve the bariatric surgery consultation. Therefore, we decided that the Plan does not have to pre-approve the bariatric surgery consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the saline infusions, ceftriaxone sodium injections and intravenous infusions provided from February 3, 2021, through February 16, 2021.

You asked the Plan to waive the cost for the saline infusions, ceftriaxone sodium injections and intravenous infusions. You say that the claims are being treated as an office visit, but you only see the doctor once a week during the infusions. You say that you should not be charged a $45 copayment when you only see a nurse. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each Medicare-covered Part B drug from an in-network provider and a $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules).

You have been asked to pay $46.14 for each date of service. The total amount you owe is $645.96 ($46.14/visit x 14 visits = $645.96). The saline infusion and ceftriaxone sodium injection fall within the "Medicare Part B Prescription Drugs" benefit category. The intravenous infusion falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The saline infusion and ceftriaxone sodium injection are considered a Part B drug that applies 20% coinsurance. The intravenous infusion is considered a physician service that applies a $45 copayment when provided at a specialist's office.

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 cost for the saline infusions, ceftriaxone sodium injections and intravenous infusions provided from February 3, 2021, through February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensor, for the enrollee.

You asked the Plan to pre-approve the diabetic supplies. You say that the supplies are necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The enrollee is not insulin-treated with multiple (three (3) or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. The enrollee does not have an insulin treatment regimen that requires frequent adjustment by the beneficiary on the basis of blood glucose monitor or continuous glucose monitor testing results. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 2 Sensor, for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 27, 2020 to July 30, 2020.

You asked the Plan to pay for home health services. You say that you would like reconsideration because this claim was billed with a 30-day period of care. The Plan denied your request. The Plan says this claim was billed with a 60-day period of care.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was billed for 33 days. This is beyond to allowable 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 27, 2020 to July 30, 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on January 5, 2021.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because this service
was billed correctly. The Plan denied your request. The Plan says this claim was billed with an inappropriate
place of service code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 99214 is not supported in the record. Specifically, it is not appropriate to bill place of
service code 12 for the member's home with CPT code 99214. Additionally, the documentation submitted does
not include medical records to verify that Medicare coverage criteria have been met. Based on this information,
we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that
the Plan does not have to pay for the office visit (99214) provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on February 14, 2020.You asked the Plan to pay fordrug testing. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample is taken is reported as the Place of Service (POS) We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 -indicating an independent laboratory setting -is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on February 14, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe walker provided on November 24, 2020.You asked the Plan to waive the coinsurance forthe walker. You say that you were told this was fully covered and there would be no charge. You say that this was supposed to be covered by your insurance.The Plan denied your request. The Plan says the coinsurance 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 20% of the monthly cost until the item is deemed a purchase. You have been asked to pay $15, which is 20% of the allowed amount for the walker. The allowed amount is $74.98 (20% x $74.98 = $15). The walker falls within the "Durable medical equipment (DME) and related 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 coinsurance forthe walker provided on November 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided by a participating provider on November 21, 2020.You asked the Plan to waive the copayment fora CT scan. You say that you do not agree with this copayment.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 $250 to $300 copayment for outpatient diagnostic tests/in-network/diagnostic radiology services. You have been asked to pay $286.54 which is less than your copayment amount of $250 to $300 copayment for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within  the outpatient diagnostic tests/in-network/diagnostic radiology 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 fora CT scan provided by a participating provider on November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0676).You asked the Plan to pre-approvea pneumatic compression device. You say that this is needed to prevent blood clots.The Plan denied your request. The Plan says that this is excluded from coverage by Medicare.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and miscellaneous supplies (99070) provided on November 13, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, surgical extractions, deep sedation/general anesthesia, and miscellaneous supplies. You say that all of these procedures were done to better your quality of life. The Plan denied your request. The Plan says your request is not medically necessary because these services are not covered under Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), two surgical extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), each subsequent 15 minute increment of deep sedation/general anesthesia (D9223), and miscellaneous supplies (99070) provided on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided thatthe Plan does not have to pay 50% of the cost forthe pulpal regeneration (D3355) provided on February 15, 2021.You asked the Plan to pay 50% of the cost forthe dental service. You say that you were in excruciating pain. You also say that the service was medically necessary.The Plan denied your request. The Plan says pulpal regeneration is not listed as a covered service.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 pulpal regeneration is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay 50% of the cost forthe pulpal regeneration (D3355) provided on February 15, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 7, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 physician services provided on January 7, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on December 31, 2020 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to verify eligibility and obtain the proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 a practitioner visit provided on December 31, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the provisional splinting (D4321) provided on December 8, 2020.

You asked the Plan to reimburse you for the provisional splinting. You say that you understand why the provisional splinting was denied. You say that you do not understand why the x-ray was denied. You also say that you were previously told that x-rays are covered.The Plan denied your request. The Plan says provisional splinting is not listed as a covered service.

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 reimburse you for the provisional splinting (D4321) provided on December 8, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 at the time of admission, you require skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As a practical matter, you did not require any skilled services on an inpatient basis. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of July 2, 2021, you required custodial services. The denial for further inpatient skilled care is upheld. 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.