Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided December 29, 2020 to January 5, 2021.
You asked the Plan to waive the copayment for the hospital services. You say that you are appealing the change in copay of medications. Older medication had no need for change and denial of medical coverage. 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 copayment per day, day's 1-6 for Inpatient hospital care. You have been asked to pay $120 ($20 x 6 days) for the hospital services. The Evidence of Coverage says that you do not pay the emergency room visit cost share if you are admitted to the hospital withing 24 hours for the same condition. Medical records were not provided, however the Notice of Denial of Medical Coverage provided indicated that "the records show you were admitted to the hospital". Therefore, the inpatient copayment applies. The inpatient hospital services fall 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 the inpatient hospital services provided December 29, 2020 to January 5, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that the member's needs can be provided at an alternative level of care.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says an MRI is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
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 an MRI. Our reviewer says that the
requested MRI is not medically reasonable and necessary. Our physician reviewer found that there is no
documentation of adequate conservative measures for back and hip pain. A 6-week trial of physical therapy is
needed. There are no red flags for an MRI at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for strapping provided on February 12, 2020.

You asked the Plan to waive the copayment for strapping. You say that you only paid $20 in the past and disagree with the charges. 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 outpatient surgery, including services provided at hospital outpatient facilities. 

You received strapping at an outpatient hospital facility on February 12, 2020. Strapping is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $135.83, which is less than the $250 copayment. 

You have been asked to pay the total copayment amount of $135.83 for strapping. Strapping falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 strapping provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular risk testing (81479) provided on December 16, 2020.

You asked the Plan to pay for hereditary cardiovascular risk testing. You say that this is supported by the records. 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 hereditary cardiovascular risk testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular risk testing (81479) provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copay for the office visit provided on November 9, 2020.

You asked the Plan to waive the copay for the services provided. You say that you had a visit with your primary care physician. The Plan denied your request. The Plan says that there is a copay for behavioral health office visits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copay for each primary care physician office visit.

The Plan says you must pay a $10 copay for the services provided. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copay for services in a primary care physician's office. Therefore, we decided that the Plan has to waive the copay for the office visit provided on November 9, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for home health aide or certified nurse assistant, providing care in the home; per hour, provided from June 29, 2020, to August 4, 2020.
You asked the Plan to reimburse you for the private duty nursing. You say that you need these claims to be resolved. You say that you have been very frustrated with this process. You say that the services were medically necessary due to the enrollee's declining medical condition. You also say that the enrollee had an enhanced benefit for Private Duty Nursing. The Plan denied your request. The Plan says there was no physician order for these services. The Plan says these services were non-skilled and custodial in nature and were provided by home aides or nurse's aides. The Plan also says that the services that were rendered do not meet the criteria for Private Duty Nursing under the enrollee's Evidence of Coverage.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the private duty nursing have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for home health aide or certified nurse assistant, providing care in the home; per hour, provided from June 29, 2020, to August 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health services provided from January 1, 2020, to June 12, 2020.
You asked the Plan to reimburse you for the home health services. You say that the enrollee's insurance plan covers home health care. You say that there were no agencies that provided the necessary services for the enrollee. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says the provider in this case is not a certified Medicare provider. The Plan says that if a home health care provider does not participate in Medicare, that the plan will not pay for the services.
The Plan must follow Medicare rules. Medicare rules say that that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to reimburse you for the home health services provided from January 1, 2020, to June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (14021) provided on September 15, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.

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 14021 is "Adjacent tissue transfer or rearrangement,
scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm."

We asked our coding 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 services. Our reviewer says that the use
of CPT code 14021 is not supported by the records provided. Our coding reviewer found that the medical
records provided do not include documentation to meet criteria to validate that an "Adjacent tissue transfer or
rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm" was performed on September 15,
2020. Therefore, this service cannot be verified.

We looked at this coder'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 pay for the services (14021) provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on November 28, 2020.

You asked the Plan to pay for the dental services. You say that you used a dentist on the Plan's list. You say that your insurance indicates they pay 100% for cleanings. You say that you should not be responsible for $95. You also say that you are on a fixed income. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that 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 and comprehensive oral evaluation and periapical x-ray are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 3, 2018. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, the unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on November 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and periodontal maintenance (D4910) provided on November 17, 2020.
You asked the Plan to pay for the x-ray and periodontal maintenance. You say that these services were necessary, and you do not recall having a panoramic x-ray in the recent past. The Plan denied your request. The Plan says you have exceeded the frequency allowed by the dental benefit for these services. Panoramic x-rays or complete series x-rays can be covered once every three years. You had a full series of x-rays done in mid-2018 which included intraoral periapical x-rays, bitewing x-rays, and a panoramic x-ray. In addition, only two cleanings may be covered per year. You had periodontal maintenance cleanings done in March and July of 2020, and therefore the third cleaning on the date in question exceeds the annual limit of two. These services cannot be 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, the x-ray and periodontal maintenance are requested in a frequency not covered under this benefit. Documentation supports that you had a previous panoramic x-ray and complete x-ray series done in 2018 and two previous periodontal maintenance cleanings in 2020. Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) and periodontal maintenance (D4910) provided on November 17, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance transportation provided October 28, 2020.
You asked the Plan to pay for air ambulance transportation. You say that the care provided was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that emergency transportation was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance transportation. Our reviewer says that the requested services were medically necessary and reasonable. Our physician reviewer found that this is a case of a 39-year-old female with a history of heart transplant who presented to the emergency department complaining of chest pain and dental pain. She was transported to a hospital specialized to treat those with prior history of heart transplant. Given this enrollee's complicated cardiac history which includes history of heart transplant, it is medically appropriate to transfer her to the facility where her heart transplant physician and specialists in heart transplant care are located. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transportation have been met. Therefore, we decided that the Plan has to pay for air ambulance transportation provided October 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 27, 2020.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain indications.
The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare covers cardiovascular disease screening tests for certain indications, the documentation does not support that the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam, problem focused (D0140) bitewing x-ray (D0270) and resin-based composite, two surfaces, posterior (D2392) provided January 4, 2021.

You asked the Plan to pay for the dental services. You say that you received a check for $61.50 of the $309 you paid upfront to the dentist. You are appealing the denial of the exam that's stated on the receipt and the amounts paid on the filling and bitewing x-rays. The Plan denied your request. The Plan says the claim was processed correctly per the Evidence of Coverage.

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 health plan contract says that you pay 50% for dental services received out of network. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Services not listed on the Description of Benefits is not covered by the plan. Limited oral exam is not listed as a covered benefit.

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 limited oral exam, problem focused (D0140) bitewing x-ray (D0270) and resin-based composite, two surfaces, posterior (D2392) provided January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750 x2), and pontic (D6240).
You asked the Plan to pre-approve retainer crowns and pontic. You say that a removeable prosthesis is not appropriate as there is only 1 missing tooth. There is gross recurrent decay. Periodontal prognosis is excellent and can be fixed with a bridge. The Plan denied your request. The Plan says the service in question is not medically necessary at this time.
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 retainer crowns and pontic when the services are medically necessary and reasonable. 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 retainer crowns and pontic. Our reviewer says that the services at issue are not medically necessary at this time. Our physician reviewer found the records do not show there is a physical or neurological disorder that precludes the use of a removable prosthesis. The plan allows for a fixed prosthesis only for exceptional cases when this criterion applies. As the criteria has not been met, and there is an alternative available, the fixed bridge is not necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of retainer crowns and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6750 x2), and pontic (D6240).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing provided on November 17, 2020.
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing code 0012M is not covered by Medicare for date of service November 17, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pacemaker evaluation services provided on December 7, 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 pacemaker evaluation services provided on December 7, 2020 by an out of network (OON) provider.