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

We decided that the Plan does not have to pay for laboratory services provided on July 24, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved 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 did not pre-approve the laboratory services. 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 laboratory services provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on May 28, 2020.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the provider of the services you received does not participate in Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe physician services provided on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plandoes not haveto pay forinpatient hospital care after spinal surgery for the enrollee.You asked the Planto pay foracute inpatient hospital care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no active complex medical conditions that require inpatient care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is to undergo a procedure, which is not on the inpatient only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities that would knowingly warrant two midnights of care. The enrollee should present for, undergo and be monitored following the procedure as an outpatient. Should a need for prolonged care (i.e. two midnights) arise, the enrollee can be converted to inpatient status at that time, under the two midnight rule.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient hospital care after spinal surgery for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved 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 th ePlan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical procedure/injection provided on September 30, 2019.You asked the Plan to waive the copayment forthese services. You say that you do not agree with the place of service and should not owe this copayment.The Plan denied your request. The Plan says that 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 $295 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for these services. These services fall within the Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient surgical procedure/injection provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided.

You asked the Plan to reimburse you for the dental service. You say that the service was necessary.The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 frequency limit of 2 oral exams per calendar year has been exceeded. The record shows that the Plan paid for oral exams that you received. The Evidence of Coverage clearly states that you are is responsible for the full cost of services received greater than the specified limits.Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear upgrades you received on June 4, 2020.
You asked the Plan to pay for the upgrades. The Plan denied your request. The Plan says these services are not covered.
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 does not cover eyewear upgrades or enhancements.. We looked at the file and the Plan's rules. The Plan contract clearly states that eyewear upgrade or enhancements are not covered. Based on this information, we decided that the Plan's rules for coverage of the requested upgrades have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear upgrades you received on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental exam provided on July 13, 2020.
You asked the Plan to pay for the dental exam. You say that the Plan should pay this claim. The Plan denied
your request. The Plan says two exams were already covered for the year.
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. Two oral exam claims were submitted and paid for the year 2020.
Therefore, we decided that the Plan does not have to pay for the dental exam provided on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that each time the enrollee has been discharged to a skilled nursing facility, he returns to the hospital.The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at anacute care hospital (ACH)for recurrent rectal bleeding and pneumonia. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the post stabilization services provided April 17, 2020 to April 19, 2020.
You asked the Plan to pay for the post stabilization services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post stabilization services. Our reviewer says that the documentation supports that the services rendered were medically reasonable and necessary. Our physician reviewer found the enrollee was admitted with RSV. The Plan was notified of the admission of the patient and approved admission. The Plan demands 2 negative Covid tests prior to transfer. The enrollee was transferred in a reasonable period of time after the second test (a Plan specific demand) and was receiving necessary management in meantime. Therefore, the enrollee met criteria for the services rendered. 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 post stabilization services have been met. Therefore, we decided that the Plan has to pay for the post stabilization services provided April 17, 2020 to April 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) and drugs or medicaments (D9630) provided from July 20, 2020, to August 3, 2020.
You asked the Plan to pay for the gingival irrigation and drugs or medicaments. You say that you did not know that you had to specify which provider you wanted to see at the dental office. You say that you thought all of the dental provider's at this location were in network. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan says that drugs or medicaments is not listed as a covered service either.
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 gingival irrigation (D4921) and drugs or medicaments (D9630) provided from July 20, 2020, to August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spinal cord stimulator.You asked the Plan to pre-approvethe requested services. You say that you have severe back pain.The Plan denied your request. The Plan says you are not being treated for any of the required conditions.The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain medical indications.We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that you have chronic neck pain, shoulder pain and also low back pain. You hada prior spinal cord stimulator(SCS),but it "quit working" and "stopped helping". You have had multiple medication trials, cervical steroid injections without sustained pain relief, and intra-articular shoulder steroid injections. You do nothave an evidence based indication for a SCS trial. The request does notmeet the coverage criteria. Therefore, the request 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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal cord stimulator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services received from May 8, 2020 to May 27, 2020.You asked the Plan to pay forthe SNF services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received by the enrollee were 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 above 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that the enrollee required the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services were required on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis, at a SNF 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 decidedthat the Plan does not have to pay forthe skilled nursing facility (SNF) services received from May 8, 2020 to May 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on March 31, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you thought any costs related to COVID will be waived. You say that you are questioning why you are responsible for the ER copayment. The Plan denied your request. The Plan says the copayment 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 $120 copayment for emergency services in an emergency room. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency Care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on March 31, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the port flush services received by an out-of-area provider.

You asked the Plan to pay for the port flush services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services received were not considered urgent or emergent.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.  

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 port flush services. Our reviewer says that the documentation supports that the port flush services received were medically reasonable and necessary. Our physician reviewer found the documentation shows that you could not have foreseen requiring the services prior to leaving your service area. The port required flushing. The records indicate that the care provided was medically necessary and it would not have been medically reasonable to delay the services until when enrollee returned to her service area.

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 port flush services have been met.Therefore, we decided that the Plan has to pay for the port flush services received by an out-of-area provider.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a speech generating device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says this accessory is a deluxe feature which exceeds medical need.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based on the medical records provided, there is no documentation that the enrollee meets the criteria for
the NeuroNode 3.0 EMG + Spatial sensor including all necessary software and accessories. Records indicate
that the enrollee achieved near 100% accuracy with the approved speech generating device (E2510) and do not
indicate medical necessity of the NeuroNode 3.0 EMG + Spatial sensor including all necessary software and
accessories.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a speech generating device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on
August 25, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were referred to
this treating provider by your in-network dentist. You also say that the Plan has never had an in-network oral
surgeon where you live. The Plan denied your request. The Plan says benefits for the problem focused limited
oral evaluation have been satisfied and the frequency limitation has been exceeded.
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, exams are limited to two procedures
per calendar year. The record shows that you received exams on February 18, 2020, and June 30, 2020, and
your exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation provided on August 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services with CPT codes A0427 and A0425 provided on April 29, 2020.You asked the Plan to pay forCPT codes A0427 and A0425. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Medicare says ambulance claims need to be edited to assure the presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue code 540. The file shows that the claim was not billed with either a QM or QN modifier.Therefore, we decided that the Plan does not have to pay forthe ambulance services with CPT codes A0427 and A0425 provided on April 29, 2020.