Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and preventive procedure provided on August 31, 2020.You asked the Plan to pay forthe periodic oral evaluation, prophylaxis, and preventive procedure. You say that your plan documentation does not state that preventive services are subject to the $1,000 benefit maximum.The Plan denied your request. The Plan says your $1,000 benefit maximum was met prior to the processing of this claim.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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dentalservices. The record shows that you met the annual maximum benefit on March 9, 2020 and your annual maximum benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, prophylaxis, and preventive procedure provided on August 31, 2020.Your complaint about the documentation from the Plan being unclearis 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 6, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that 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 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 subsequent nursing facility care provided on August 6, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D4266 and D7953).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this 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 pre-approve
dental services (D4266 and D7953).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient surgery provided on June 23, 2020.You asked the Plan to pay forInsertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869). You say that this procedure is not experimental.The Plandenied your request. The Plan says the clinical value and effectiveness of the Vertiflex Superion Interspinous device has not been demonstrated in the peer-reviewed literature.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 review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869). Our reviewer says that the requested items/services were not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy. Hardware is not needed for spinal stenosis surgery. There is no instability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22869) have not been met.Therefore, we decided that the Plan does not have to pay forthe outpatient surgery provided on June 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided on August 24, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that if you had received adequate care, the ambulance trip would have not been necessary.The Plan denied your request. The Plan says the copayment for this service processed correctly in this case.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 $275 copayment for ambulance services.You have been asked to pay a $275 copayment for the ambulance services. The services provided fall 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 forthe ambulance services provided on August 24, 2020.Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (88271, 88275) provided on August 17, 2020.
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was performed for screening purposes.
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 test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing (88271, 88275) provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses (V2781) received on September 28, 2020.
You asked the Plan to pay for progressive lenses. You say that you have used the same vision provider for years and did not see any warning about having to use a preferred provider in the Plan's EOC. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that progressive lenses will be denied as noncovered. We looked at the file and Medicare rules. The request is for progressive lenses. Based on this information, we decided that Medicare rules for coverage of progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) received on September 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, theenrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower level of care.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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to waive the copayment forthe inpatient care and emergency room services provided from January 11, 2019, to October 8, 2019.You asked the Plan to waive the copayment forthe inpatient care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the copayment has processed correctly and no reimbursement is due.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 $175 copayment per day, days 1 to 7 and a $120 copayment for inpatient hospital care and emergency services, respectively. You have been asked to pay a total cost share of $1,696.72 for the inpatient careand emergency room services. Theinpatient care falls within the inpatient hospital care and emergency services benefit category. Before paying this amount, you had not yet reached the out-of-pocket maximum of $2,750. 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 forthe inpatient care and emergency room services provided from January 11, 2019, to October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from July 24, 2020, to July 31, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you were told that the provider was participating. 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 $250 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from July 24, 2020, to July 31, 2020. Therefore, you are responsible to pay a $250 copayment for days 1-6 (July 24, 2020, to July 29, 2020). $250 (copayment) x 6 (inpatient days) = $1,500. You have been asked to pay the total copayment amount of $1,500 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 copayment for an inpatient hospital stay from July 24, 2020, to July 31, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on October 16, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you had no other option
but to go to the emergency room. You say that you shouldn't have to pay this big of a 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 $50
copayment for emergency care.
You have been asked to pay a $50 copayment for an emergency room visit. Since an emergency room visit was
provided, the correct copayment has been applied. An emergency room visit falls within the emergency care
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit
provided by a participating provider on October 16, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.
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. The patient
is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19 following a recent stroke. The
enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from
the ventilator to a tracheotomy collar. There is no evidence that the enrollee requires services that are not
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care needs. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for LTACH services.
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on September 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that referring provider is also out-of-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 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 services provided on September 21, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on June 19, 2020, to September 9, 2020 by an out of network provider.
You asked the Plan to pay for the behavioral health services. You say that the services were requested by the facility and medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided on June 19, 2020, to September 9, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering performed on September 16, 2020.
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 procedure code 76377 is not supported.
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 76377 is 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. We find that CPT code 76377 is not supported in the medical record. Specifically, the code was not billed in conjunction with a CT, MRI, ultrasound, or other tomographic modality. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 3D rendering performed on September 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided from January 21, 2020 to September 8, 2020.
You asked the Plan to pay for this service. You say that these claims should be paid as they were covered by the Plan previously. The Plan denied your request. The Plan says the previous claims were paid in error and adjudicators have been educated, and that those claims will remain paid. The Plan states that the provider has not been Medicare eligible since 2016. The Plan states that any additional services provided will not be covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program. The services at issue in this appeal were provided by a practitioner who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided from January 21, 2020 to September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for dizziness and had surgical resection of a left sided cerebellar mass (metastatic from previously 
diagnosed breast cancer). Medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 
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 IRF admission and services.