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

We decided that the Plan does not have to waive the copayments for wound care services you received at an outpatient hospital facility from February 1, 2021, to March 15, 2021.

You asked the Plan to waive the copayments for the wound care services. You say that you were never told that these services would be billed as an outpatient visit. If you had known this would be billed this way, you would have gone to an office-based doctor. You stated that the doctor and the facility shouldn't both be charging for these services. The Plan denied your request. The Plan says you were charged these copayments 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 $95 copayment for surgery or other services at an outpatient hospital facility.

Records show that you received wound care services ten times between February 1, 2021, and March 15, 2021. You received these services with a doctor based in an outpatient hospital facility. You have been asked to pay a $95 copayment per visit for the wound care services. Because the facility where the wound care services were received is considered an outpatient hospital facility, the wound care services fall within the surgery or other services at an outpatient hospital facility 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 copayments for wound care services you received at an outpatient hospital facility from February 1, 2021, to March 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that at this point, the enrollee's care needs, as a practical matter, can be provided 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99205) provided on
August 11, 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 service 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 $15 copayment for each covered visit or consultation in an outpatient location with a specialist.
You have been asked to pay a $15 copayment for the specialist office visit provided. 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 office visit (99205) provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography (93306) provided on January 9, 2021.

You asked the Plan to pay for the echocardiography. You say that you would like reconsideration because the documentation supports that this provider rendered the professional component of the echocardiography. The Plan denied your request. The Plan says this service exceeds Medicare's Medically Unlikely Edits and the documentation does not include the member's name to verify the service.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the echocardiography have not been met. Specifically, the documentation submitted does not include the member's name to verify the services rendered. Therefore, we decided that the Plan does not have to pay for the echocardiography (93306) provided on January 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a problem focused limited oral exam (D0140) and an occlusal adjustment (D9951) provided on March 23, 2021.
You asked the Plan to pay for a problem focused limited oral exam and an occlusal adjustment. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered.
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, it only covers one limited exam to evaluate a problem (D0140) per plan year. The record shows that you received a limited exam to evaluate a problem on March 2, 2021. The Plan's benefit does not cover occlusal adjustments (D9951). Therefore, we
decided that the Plan does not have to pay for a problem focused limited oral exam (D0140) and an occlusal adjustment (D9951) provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist on March 10, 2021.
You asked the Plan to pay for the dental services. You say that you called prior to receiving these services and you were told that this dentist was in-network. The Plan denied your request. The Plan says you were not given incorrect information. The Plan says that the phone records show you called asking about root canal benefits. During that call, you advised that the provider was in network, not the Plan. The phone records show that the Plan agent advised you that root canals are covered in-network at 30% and out-of-network they are not covered at all.
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 dental services you received from an out-of-network dentist on March 10, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary as transfer would provide no significant clinical advantage. Transfer may be considered when 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs SNF admission in Pennsylvania so that his daughter is able to help out. The Plan denied your request. The Plan says that the enrollee can continue to receive appropriate intensive rehabilitation services at the inpatient rehabilitation facility.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance services provided January 8,
2021.

You asked the Plan to pay for the non-emergency ambulance services. You say that it was medically necessary
for the enrollee's condition to be transported in an ambulance. The Plan denied your request. The Plan says the
criteria for coverage was not met.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 non-emergency ambulance services. Our
reviewer says that the requested service was not medically necessary and reasonable. Our physician reviewer
found based on the medical records provided there is no documentation to support that other means of transport
(such as stretcher van or wheelchair van) were contraindicated for this patient on January 8, 2021, for the
transport from the hospital emergency department back to her home. In addition, there is no documentation to
support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a
fully-equipped ambulance can provide.

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 non-emergency ambulance services have not been met. Therefore, we
decided that the Plan does not have to pay for the non-emergency ambulance services provided January 8,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on May 4, 2021.

You asked the Plan to pay for the eye refraction. You say that you are having cataract surgery and you believe the eye exam was something you did not want, and you should not have to pay this exam. The Plan denied your request. The Plan says Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses/contacts, and this plan only covers eyewear post cataract surgery.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on May 4, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for MTHFR testing provided on November 5, 2020.
You asked the Plan to pay for MTHFR testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that this testing is not covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that MTHFR testing would not be covered. This test is not excluded from Medicare coverage for the geographic location in which the testing was performed. Under Medicare rules, this means MTHFR testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for MTHFR testing provided on November 5, 2020.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided on
September 24, 2020.
You asked the Plan to pay for ambulance transportation. You say that this was medically necessary. The Plan
denied your request. The Plan says the enrollee was not transported to a covered destination.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ambulance transportation. Our reviewer says
that the requirements for coverage of ambulance transportation have not been met. Our physician reviewer
found the documentation does not support that other means of transport were contraindicated for this patient on
September 24, 2020. The documentation does not support that the patient needed the expertise, services and
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular gene risk panel including MTHFR gene analysis provided on September 1, 2020.

You asked the Plan to pay for the cardiovascular gene risk panel including MTHFR gene analysis. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says this is not a Medicare covered service.

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 the cardiovascular gene risk panel including MTHFR gene analysis. 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 medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and is occasionally useful in rare familial inherited cardiac conditions. In addition, there are no guideline indications for specific MTHFR testing as well in either asymptomatic or established cardiovascular disease patients and this is not recommended, especially without a familial history of thrombophilia.

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 cardiovascular gene risk panel including MTHFR gene analysis have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular gene risk panel including MTHFR gene analysis provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on December 4, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. The services were not urgent or emergent and were not approved of in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit (99214) provided on December 4, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (dental code D0150) you had on April 20, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like these services covered. The Plan denied your request. The Plan says comprehensive oral evaluations are covered once every three years. Records show that you last received a comprehensive oral evaluation on June 25, 2019. You were not entitled to another comprehensive oral evaluation until after June 25, 2022.
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 the comprehensive oral evaluation once every three years.
Records show that you received your last covered comprehensive oral exam less than three years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (dental code D0150) you had on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX-SCC testing provided on December 28,
2020.
You asked the Plan to pay for the DecisionDX-SCC test. You say that you would like reconsideration because
this testing is medically necessary due to the clinical utility of its results. The Plan denied your request. The
Plan says this test is 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 looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of the DecisionDX-SCC test have not been met. Per Molecular Diagnostic Services
(MolDX), this test has been evaluated via the Technical Assessment and has not been found to meet clinical
utility criteria. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay
for the DecisionDX-SCC testing provided on December 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for spirometry provided on October 9, 2020.

You asked the Plan to pay for spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation (94010). You say that the Plan should pay this claim. The Plan denied your request. The Plan says medical records supporting the service were requested but not received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 94010 is not supported in the medical record. Specifically, there are no clinicals supporting medical necessity in the case file. Based on this information, we decided that Medicare rules for coverage of spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation (94010) have not been met. Therefore, we decided that the Plan does not have to pay for spirometry provided on October 9, 2020.