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

We decided that the Plan does not have to waive the cost share for the outpatient surgery services provided on July 21, 2020.

You asked the Plan to waive the cost share for the services provided. You say that you should only have a 30% coinsurance. The Plan denied your request. The Plan says the claim processed 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 30% coinsurance for each covered surgery in an outpatient hospital. 

The file shows that you received surgery services in an outpatient hospital facility. You have been asked to pay a 30% coinsurance for the services provided. The services fall within the outpatient surgery 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 cost share for the outpatient surgery services provided on July 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixteen (16) services of home health/hospice aide in home health or hospice setting (CPT code G0156 x16).

You asked the Plan to pre-approve the services. You say that you need more time to recover from your procedure as you underwent to a bone tissue rebuilding procedure and not just a usual surgery. The Plan denied your request. The Plan says a home health aide is not medically necessary for your condition.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 services. physician reviewer found in order to require Home health care skilled services, you must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician. Additionally, you must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound means leaving home is a major effort. Our physician reviewer found in this case, the documentation does not support that you require skilled nursing services or skilled rehab services to provide treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. As you no longer require skilled care, the requested home health aide is not medically necessary. The requested home health services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sixteen (16) services of home health/hospice aide in home health or hospice setting (CPT code G0156 x16).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the unspecified preventive service (D1999).

You asked the Plan to pay the in-network rate for the unspecified preventive service. You say that this provider is listed as in network on the website. The Plan denied your request. The Plan says unspecified preventive service 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 unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in-network rate for the unspecified preventive service (D1999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiac gene panel (81408, 81479).

You asked the Plan to pay for a comprehensive cardiac gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiac gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiac gene panel (81408, 81479).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) rendered by the out of network (OON) provider on December 23, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The record indicates that the transfer of the enrollee to this hospital was non-emergent. As such, the hospital had an obligation to request authorization for this service prior to the enrollee being transferred. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) rendered by the out of network (OON) provider on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the requested care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have 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 you are a 70 year old male with cervical fracture, seizures and pulmonary embolism, currently in an inpatient rehab facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 the admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for an injection. We decided that the Plan does not have to waive the coinsurance for an injection and copayment for a radiology services and specialist services.

You asked the Plan to waive the coinsurance and copayment for an injection, radiology services and specialist services. You say that you do not agree with these charges. The Plan says that the correct charges have been applied to the services that were provided.

We decided that the Plan has to reduce the coinsurance for an injection.

You cannot be charged more than a 20% coinsurance for an injection. The total allowed amount is $844.80. The total amount you should be asked to pay for injections is $168.96 ($844.80 x 20% coinsurance = $168.96). Therefore, we decided that the Plan has to reduce the coinsurance for an injection.

We also decided that the Plan does not have to waive the coinsurance for an injection and copayment for a radiology services and specialist services.

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% coinsurance for an injection, a $160 copayment for radiology services and a $45 copayment for specialist services. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection and copayment for a radiology services and specialist services.

Total Amount Being Asked to Pay: $877.02

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health nursing services.

You asked the Plan to pre-approve continued services. You say that the care is vital to the enrollee's healing. The Plan denied your request. The Plan says there are listed problems needing the care of a licensed nurse.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 continued services. Our physician reviewer found that the enrollee has a history of primary osteoarthritis of the knees and left hip who fell at home and broke her left femur. There is no indication that she has a feeding tube, parental medications or complex wound care issues. There is no indication that she has had any recent medication changes or hospitalizations. There has not been a recent decline in function. The documentation does not support that the enrollee requires skilled nursing services to provide treatment that is medically necessary. Therefore, the requested home health services are not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health nursing services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revascularization services coded 37234.

You asked the Plan to pay for the revascularization services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 37234 is revascularization, Endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).

We find that CPT code 37234 is not supported in the medical record. Specifically, this is an add-on code. This add-on code was not billed with an acceptable primary procedure code. Based on this information, we decided that Medicare rules for coverage of the revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization services coded 37234.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological exam and evaluation (CPT code 92014) provided by an out-of-network provider.

You asked the Plan to pay for the services. You say that there was a referral for services. The Plan denied your request. The Plan says they allow for out-of-network services and payment if the plan authorizes the service, and/or if it is delivered in an emergency setting, and/or if there are not network providers available for these services. The Plan states the documentation shows that no authorization was obtained, it was not an emergency service, and there are network providers available for the delivery of this service.

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 ophthalmological exam and evaluation (CPT code 92014) provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sensors for a therapeutic CGM (K0553) provided on October 28, 2020.

You asked the Plan to pay for sensors for a CGM. You say that the enrollee is using the requested medically necessary items with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document submitted as proof of delivery indicates a requirement for a signature but is not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for sensors for a therapeutic CGM (K0553) provided on October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the polycarbonate lenses.

You asked the Plan to pay for the polycarbonate lenses. You say that you were not aware of the $100 benefit limit for routine eye wear. The Plan denied your request. The Plan says the claim processed correctly according to your benefit.

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 $100 towards the purchase of routine (non-Medicare covered) prescriptions glasses or contact lenses each calendar year. 

We looked at the file and the Plan's rules. In this case, the Plan submitted evidence that $100 was applied towards the purchase of routine prescription glasses. Based on this information, we decided that the request for payment of the polycarbonate lenses is in excess of the Plan's supplemental benefit limit. Therefore, we decided that the Plan does not have to pay for the polycarbonate lenses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on December 2, 2020.

You asked the Plan to pay for the oral evaluation. You say that this was your second oral evaluation of the year and should be covered. The Plan denied your request. The Plan says you already had two oral evaluations this year, and therefore the benefit was exceeded on the December date of 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 exceeded the frequency allowed by the Plan's benefit. Documentation was provided that shows that the Plan paid for oral evaluations in May and July of 2020, and therefore your exam in December exceeded the maximum of two evaluations per calendar year. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx genomic profiling test provided to the enrollee on November 1, 2020.

You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says the laboratory is not Medicare-certified.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.

You are not eligible to bill Medicare. The Plan did not pre-approve the test. 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 FoundationOne CDx genomic profiling test provided to the enrollee on November 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on November 5, 2020.

You asked the Plan to pay for the evaluation. You say that you were involved in a car accident that resulted in injuries to your face and teeth. You needed a problem-focused oral evaluation and say that the Plan should cover this because you still had funds left in your benefit allowance. The Plan denied your request. The Plan says they have already paid for one problem-focused oral evaluation for you this year. The benefit maximum of one per plan year has been exceeded, therefore no payment can be made.

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 have exceeded the frequency allowed by the Plan's benefit. Documentation was provided showing that the Plan paid for a problem-focused oral exam for you in July of 2020. Your benefit maximum of one problem-focused exam per plan year has been exceeded. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) provided on November 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided on September 27, 2020.

You asked the Plan to waive the copay for the ambulance services. You say that you should not have to pay for the ambulance fee to a facility able to accommodate you. The Plan denied your request. The Plan says the claim was processed 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 $255 copay for ambulance services.

You have been asked to pay a $255 copay for the ambulance services. The services 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 copay for the ambulance transportation services provided on September 27, 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.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a 67-year-old male who was admitted to the current acute care facility with acute respiratory failure requiring mechanical ventilation support, feeding tube, and antibiotics. The patient appears agitated and unstable at this time and requires ventilation weaning attempts prior to being appropriate for transfer which can safely be completed at the current facility over the short-term. The patient does not require services at the LTACH that are not already available at the current facility. Consequently, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer may be considered soon when the patient is more stable and treatment has completed.

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.