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

We decided that the Plan does not have to pay forthe medical services provided on September 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe anticoagulant management (93793). You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says this service was not urgent or emergent and prior 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve theitem/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 forthe medical services provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tymlos 80 mcg dose pen injector for the enrollee.

You asked the Plan to pre-approve the injector. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Tymlos 80 mcg dose pen injector for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74176) performed on September 3, 2020.
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you feel you paid more than you should have for these services. 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 $150 copayment for diagnostic and nuclear medicine radiological services excepting mammography, ultrasounds, and X-rays. You have been asked to pay a $150 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74176) performed on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided.

You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient mental health services. Our reviewer says that inpatient services were not medically necessary. Our physician reviewer found the enrollee does meet the criteria for treatment in
an acute inpatient mental health facility beyond the date in question, forward and could have been treated in a lesser restrictive setting as he was not showing active suicidal or homicidal ideation, auditory or visual hallucinations, ordelusions, and was not showing any aggression.


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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic or therapeutic injections (62323) provided from May 5, 2020, through June 16, 2020.
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 services 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 $395 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay $1,185 ($395 copayment x 3) for the injections provided. These services are considered as outpatient surgery. The letter from the Plan dated June 18, 2020, regarding the waiver of out of pocket costs does not apply to these services provided as it states that copayments, coinsurance, and deductibles for outpatient surgery will not be waived. 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 diagnostic or therapeutic injections (62323) provided from May 5, 2020, through June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crown (D6058) provided on January
22, 2020.
You asked the Plan to pay for the abutment supported crown (D6058). You say that you were unaware of the
dental coverage through your plan. You say that the claim should be processed for payment. The Plan denied
your request. The Plan says the service is not a covered 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
abutment supported crown (D6058) provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the KIT gene targeted sequence analysis services provided
on June 10, 2020.
You asked the Plan to pay for the KIT gene targeted sequence analysis services. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed
incorrectly.
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 81272 is KIT (v-kit Hardy-Zuckerman 4 feline sarcoma
viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene
analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18).
We find that CPT code 81272 is not supported in the medical record. Specifically, the services rendered should
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of
the KIT gene targeted sequence analysis services have not been met. Therefore, we decided that the Plan does
not have to pay for the KIT gene targeted sequence analysis services provided on June 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional twelve (12) physical therapy visits.
You asked the Plan to pre-approve the additional twelve (12) physical therapy visits. The Plan denied your request. The Plan says the records do not support why the ongoing skills of a physical therapist are needed at this later stage in care. Since restorative nursing program is expected to be in place with caregiver assistance with a similar outcome expected, further skilled physical therapy is not needed.
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 the additional twelve (12) physical therapy visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for this condition and it does not appear that you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You can transition with caregiver assist into an independent home program. The specialized skill, knowledge and judgment of a qualified therapist is not 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 the additional twelve (12) physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional twelve (12) physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 24, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 carefrom 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 has network providers available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 12, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive
order for treatment in place. 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 August 12, 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 August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 4, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.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 has network providers available who can provide 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 forthe medical services provided on February 4, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on August 20, 2020.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0230) received on September 22, 2020.
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your
request. The Plan says this service is covered once per year.
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. The Plan covers D0230 once
per year.
The plan has already paid for one unit of D0230 in 2020. Based on this information, we decided that the Plan's
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay
for dental services (D0230) received on September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe travel expenses you incurred from July 13, 2020, to August 11, 2020.You asked the Plan to pay forthe expenses. The Plan denied your request. The Plan says this is not a covered benefit.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 the Plan will reimburse for travel expenses for transplant services provided under the inpatient hospital benefit. Review of the file shows that you incurred travel expenses for transplant services from July 13, 2020, to August 11, 2020. The Plan's travel reimbursement benefit for transplant services is aninpatient benefit. The records show that you were provided the transplant services at an ambulatory surgical center, an outpatient facility. The Plan does not cover travel expenses for transplants provided at an outpatient facility. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to pay forthe travel expenses you incurred from July 13, 2020, to August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimplantation of a cardiac rhythm monitor.You asked the Plan to pre-approveimplanted cardiac monitor. You say that an implantable monitor would be ideal for the enrollee.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is currently rhythm controlled with no documentation of non-invasive monitoring such as Holter monitor.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve implanted cardiac monitor. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has intermittent and recurrent atrial flutter. In this circumstance if evaluation for recurrent atrial flutter is thought to be medically necessary, then standard initial evaluation includes Holter monitoring and external prolonged event monitoring that is patient activated and/or auto-triggered. There is no documentation that the enrollee has undergone these tests or that the enrollee would not tolerate wearing an external device. An implantable loop recorder exceeds the enrollee's medical needs 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 implanted cardiac monitor have not been met.Therefore, we decided that the Plan does not have to pre-approveimplantation of a cardiac rhythm monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation supports the need for an LTACH level of care admission. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee is not medically stable and needs to stay in the hospital until he is better.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic colonoscopy provided.

You asked the Plan to pay for the diagnostic colonoscopy. You say that this colonoscopy should have been totally covered by the Plan.The Plan denied your request. The Plan says this procedure is billed as a diagnostic colonoscopy and was not billed using the codes for screening that Medicare allows; therefore, it would not be covered as a preventive service. The Plan states there was no authorization to have this service performed.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic colonoscopy have not been met. The colonoscopy was diagnostic and would not qualify for the screening benefit. Furthermore, prior authorization was not provided by the Plan for the service; therefore, this claim is upheld for not following the rules of the contract. The health plan contract says prior authorization is required for certain services at an outpatient hospital facility or ambulatory surgical  center, in-network only.Therefore, we decided that the Plan does not have to pay for the diagnostic colonoscopy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received on September 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to twelve sessions per ninety-day period, and no more
than twenty sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the records do not show that the acupuncture services
were provided chronic low back pain. Therefore, we decided that the Plan does not have to pay for the
acupuncture services you received on September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient diagnostic services (78815 and
A9587) received on August 29, 2019.
You asked the Plan to waive the coinsurance for outpatient diagnostic services. You say that the claims were
incorrectly submitted and therefore coinsurance was incorrectly charged The Plan denied your request. The
Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15%
coinsurance for diagnostic procedures and tests, X-rays, diagnostic and therapeutic radiology services.
You have been asked to pay 15% coinsurance for outpatient diagnostic services. These 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 coinsurance for outpatient diagnostic services (78815 and A9587) received on August 29, 2019.
Your complaint about your provider potentially mis-coding the services is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.