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

We decided that the Plan does not have to pay for physician's services provided on December 29, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the physician's services. 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 physician's services provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on December 1, 2020.

You asked the Plan to pay for the office visit and electrical stimulation. You say that the treatment was appropriately performed and was effective in the spinal manipulation and reduction of pain. The Plan denied your request. The Plan says Medicare does not cover non-manipulative services provided by chiropractors.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedures of the nervous system.

You asked the Plan to pay for procedures of the nervous system. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 service 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 procedures of the nervous system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a urology visit (99213, 52000) and ultrasound (76872).

You asked the Plan to waive the copayments for the urology visit and ultrasound. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 copayment for specialist visits and a $10 copayment for ultrasounds.

You have been asked to pay a $20 copayment for the urology visit (which is considered a specialist visit) and a $10 copayment for an ultrasound. 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 a urology visit (99213, 52000) and ultrasound (76872).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the progressive lens (V2781), polycarbonate lens (V2784), photochromatic tint (V2744) and anti-reflective coating (V2750) provided December 21, 2020.

You asked the Plan to provide additional payment for the progressive lens, polycarbonate lens, photochromatic tint and anti-reflective coating. You say that the lenses were medically necessary. The Plan denied your request. The Plan says the correct allowance has already been applied to the cost of the lenses.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to the Plan allowance of $250 every year.

We looked at the file and the Plan's rules. The Plan provided documentation showing that they have already applied a $250 allowance to your eyewear. Based on this information, we decided that the Plan does not have to provide additional payment for the progressive lens (V2781), polycarbonate lens (V2784), photochromatic tint (V2744) and anti-reflective coating (V2750) provided December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment injections (82948, 88307, J2550, A6403).

You asked the Plan to waive the copayment the injections. You say that the services were provided at a Cancer Center and not an outpatient hospital. The copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 copayment for outpatient hospital surgical services.

You have been asked to pay a $250 copayment for the injections. The injections fall within the outpatient hospital surgical services benefit category. The plan contacted the provider and confirmed they bill as an outpatient hospital facility. 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 injections (82948, 88307, J2550, A6403).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and the cleaning (D1110).

You asked the Plan to pay for the oral exam and cleaning. You say that you did not remember that you had already received your 2 cleanings for the year. You say that you had suffered a nervous breakdown due to the death of your daughter. You also say that the services should be covered. The Plan denied your request. The Plan says 2 cleanings per calendar year are covered. The Plan says that 2 oral exams are covered per calendar year. The Plan also says that the frequency limits for these services have been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and the cleaning (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.

You asked the Plan to waive the copayment for the specialist office visit. You say that you were only in the office for 5 minutes. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for a specialist office visit.

You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the Physician Services for visits to specialists benefit category. The medical records show you had an cardiac office visit and an electrocardiogram. 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 specialist office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391), the oral exam (D0150), cleaning (D1110), and the bitewing x-rays (D0274).

You asked the Plan to pay for the dental services. You say that the Plan confirmed that your dental coverage was active at the time you received the services. You say that you received a letter stating that you had exceeded the maximum allowance for the year. You say that the services you received were denied for not having coverage. You say that the Plan again confirmed that your dental coverage was active. You also say that you do not know what else you could have done to ensure the services were covered. The Plan denied your request. The Plan says there is a maximum benefit of $750 for dental services. The Plan also says that the maximum benefit has been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the maximum benefit of $750 for dental services has been exhausted. The record shows that the Plan paid $750 for the dental services that you received. Therefore, we decided that the Plan does not have to pay for the filling (D2391), the oral exam (D0150), cleaning (D1110), and the bitewing x-rays (D0274).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for physical therapy services (97110, 97530).

You asked the Plan to pay for the physical therapy services. You say that the services were medically necessary, and the provider is eligible for Medicare payment. The Plan denied your request. The Plan says that the plan does not issue payment to this type of provider when they are non-participating.

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.

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 provide any documentation of any policy which states that this type of provider is not eligible for payment by the plan when they are non-participating. The enrollee's coverage includes out-of-network benefits. The documentation shows the provider was enrolled in Medicare and is eligible for payment. Therefore, we decided that the Plan has to pay for physical therapy services (97110, 97530).

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81286, 81407, 81408, 81479).

You asked the Plan to pre-approve the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

We looked at the file and Medicare rules. This genetic testing was a cardiovascular risk assessment. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81286, 81407, 81408, 81479).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 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 physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a chemodenervation procedure (64615).

You asked the Plan to waive the copayment for the procedure. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $75 copayment for out-of-network specialist visits.

You have been asked to pay a $75 copayment for the procedure. The procedure falls within the out-of-network specialist visits 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 chemodenervation procedure (64615).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services.

You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were custodial in nature and are non-covered.

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 pay for the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary did not require skilled nursing or therapy services on a daily basis. By the dates in question, the beneficiary was independent with functional mobility.

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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. 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 follows Medicare rules. Medicare rules say that radiofrequency ablation is covered when specific criteria are met. 

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 radiofrequency ablation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee did not achieve 80% pain relief. Therefore, the request is deemed not medically reasonable or 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says skilled therapy was discontinued. The Plan says that the enrollee had returned to her prior level of functioning and did not have skilled nursing needs. The Plan also says that custodial care is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay an additional amount for the vision care items/services (V2299, V2781, V2750).

You asked the Plan to pay an additional amount for the vision care items/services. You say that the plan did not pay the full amount for this claim. The Plan denied your request. The Plan says that the correct cost share applied to the claim.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $250 annual eye wear allowance.

We looked at the file and the Plan's rules. The Plan contract states that vision care is covered up to a $250 annual eye wear allowance. The Explanation of Benefits for this claim indicate that the Plan only covered the items/services at issue up to $150. There is no evidence in the case record that the entire $250 eye wear allowance was exhausted prior to this claim. Based on this information, we decided that the Plan's rules for coverage of the vision care items/services have been met. Therefore, we decided that the Plan has to pay an additional $100 for the vision care items/services (V2299, V2781, V2750).

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.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the automatic external defibrillator (AED) rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that an AED is covered when specific criteria are met.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has dilated cardiomyopathy and coronary arterial disease. The criteria for the AED with integrated electrocardiogram (EKG) analysis includes having a history of myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction (LVEG) of less than 35 percent. The enrollee has a LVEF of 10-15 percent and reported intermittent short runs of ventricular tachycardia, meeting the criteria above for the LifeVest AED. The services were reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pay for the automatic external defibrillator (AED) rendered.

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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing provided September 29, 2020.

You asked the Plan to pre-approve the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage rules were not met.

The Plan must follow Medicare rules. Medicare rules say that Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for prostate cancer. 

We looked at the file and Medicare rules. Multiple CPT codes were billed for this genomic profiling. CPT code 81479 was not billed as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing provided September 29, 2020.