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

We decided that the Plan does not have to pay for the oral exam (D0120), the prophylaxis (D1110), and the
bitewing x-rays (D0274) provided on December 22, 2020.

You asked the Plan to pay for the dental services. You say that you do not believe that you have met your
annual maximum. The Plan denied your request. The Plan says there is an annual maximum of $500 for
covered dental services. The Plan also says that the annual maximum 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 annual maximum benefit has been exhausted. The record shows that you were enrolled in the optional
dental rider from July 1, 2020, to July 31, 2020, which included an annual maximum benefit of $1,000. The
record shows that you were disenrolled from the optional dental rider as of July 31, 2020, at which point you
were enrolled in the routine dental benefit. The routine dental benefit includes a $500 annual maximum benefit.

Date of Service     CPT Code      Plan Paid
6/15/2020                 D1110            $48
6/15/2020                 D0120            $46
7/6/2020                   D2740            $624
7/16/2020                 D0220            $27
TOTAL:                                          $745

After the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided
that the Plan does not have to pay for the oral exam (D0120), the prophylaxis (D1110), and the bitewing x-rays
(D0274) provided on December 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) additional home skilled nursing visits (CPT code G0299 X9).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says your records do not support the need for a skilled nurse to make more visits.
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. A doctor must certify the need for home health care services.
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. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration beyond the eleven (11) home health nursing visits that have already been approved. No acute changes are documented to support the need for further skilled home health nursing 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) additional home skilled nursing visits (CPT code G0299 X9).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services received by the enrollee on January 11, 2021 and January 20, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit services received by the enrollee on January 11, 2021 and January 20, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on January 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the patient resides in a nursing home and the provider provides acute visits. You say under traditional Medicare, this claim would not need authorization. The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is non-contract.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on January 4, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
You asked the Plan to pre-approve the surgery. You say that you are experiencing pain on your legs due to the fact that your spine is pinching your nerves, which is causing you not being able to walk, and you feel it is medically necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of your height, weight or body mass index. There is also imaging evidence of lumbar spine scoliosis, and with no documentation of the Cobb angle. There is no discussion indicating that a bone densitometry (DEXA) scan has demonstrated the lack of significant osteoporosis. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion device placement surgery at L3-4 is 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 2, 2020, by an OON
provider.
You asked the Plan to pay for the office visit. 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 a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided on September 2, 2020, by
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you are writing to appeal if the plan can cover this bill or at least reduce the amount to $100 because you are retired and on a fixed income and this will cause you hardship. The Plan denied your request. The Plan says you were charged this cost sharing 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 $300 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $300 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor (D7451)
received July 9, 2020.
You asked the Plan to pay for the removal of benign odontogenic cyst or tumor. You say that the requested
service was medically necessary. The Plan denied your request. The Plan says the requested service is not
covered under your supplemental 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
removal of benign odontogenic cyst or tumor (D7451) received July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on November 6, 2020 by an out of network (OON) provider.
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 the services were 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on November 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis services coded 20610 provided on
November 12, 2020.

You asked the Plan to pay for the arthrocentesis 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 supported by the
documentation.

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 20610 is arthrocentesis, aspiration and/or injection, major
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance.

We find that CPT code 20610 is not supported in the medical record. Specifically, the documentation submitted
does not indicate that arthrocentesis services were provided; therefore, code 20610 cannot be verified. Based on
this information, we decided that Medicare rules for coverage of the arthrocentesis services have not been met.
Therefore, we decided that the Plan does not have to pay for the arthrocentesis services coded 20610 provided
on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on November 13, 2020.
You asked the Plan to pay for the 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 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 services provided to the enrollee by an out-of-network provider on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ultrasling rendered on August 17, 2020.
You asked the Plan to waive the coinsurance for these services. You say that the item was ordered as part of your surgery without your knowledge. 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 a 20% coinsurance for in-network covered medical supplies such as splints and casts when you get them in the outpatient department of a hospital.
Review of the file shows that you received an ultrasling on August 17, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-network covered medical supplies such as splints and casts when you get them in the outpatient department of a hospital 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 the ultrasling rendered on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 9, 2019.

You asked the Plan to pay for the 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 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 services provided to the enrollee by an out-of-network provider on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine received on August 18, 2020 and the zoster (shingles) vaccine received on November 24, 2020.
You asked the Plan to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine and the zoster (shingles) vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine and the zoster (shingles) vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine and the zoster (shingles) vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine received on August 18, 2020 and the zoster (shingles) vaccine received on November 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF 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 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 there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided from June 2, 2020, through June 9, 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 June 2, 2020 to June 9, 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 from June 2, 2020, through June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted to an acute care hospital for necrotizing fasciitis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging,
tomographic (SPECT) (78452) and Regadenoson injection (J2785) and cardiovascular stress test (93015)
provided December 9, 2020.
You asked the Plan to waive the copayment for the diagnostic services and injection. You say that the provider
should charge the amount the insurance pays so there's no responsibility to you. If the doctor charged the
contracted rate, then the insurance would pay in full and then you wouldn't have copays. The Plan denied your
request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of
Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B non-chemotherapy prescription drugs and $250 per day for Medicare covered
diagnostic radiology services and $10 per day for Medicare covered tests for Medicare Part B prescription
drugs and Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay $307.35 ($47.38 + $250 + $10) for the diagnostic services and injection. The
diagnostic services and injection falls within the Medicare Part B prescription drugs and 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 the myocardial perfusion
imaging, tomographic (SPECT) (78452) and Regadenoson injection (J2785) and cardiovascular stress test
(93015) provided December 9, 2020.