Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre CGM.You asked the Plan to pre-approvea Freestyle Libre CGM. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requested Freestyle Libre CGM.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre CGM
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services, not otherwise specified (H0046) provided on May 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the mental health services. You say that you feel that this should be covered because you have been seeing this therapist for about 6 years and the sessions have really helped you deal with your depression. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 mental health services, not otherwise specified (H0046) provided on May 27, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services after January 24, 2021.You asked the Plan to pre-approveSNF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you are readyfor a lower level of care.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 24, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) servicesafter January 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasounds provided on May 11, 2020. You asked the Plan to waive the copayment for ultrasounds. You say that you were told that the copayment was waived due to COVID-19. 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 $0 copayment for mammograms and a $160 copayment for each radiological diagnostic service. You received an ultrasound on May 11, 2020. Ultrasound copayments are not waived due to COVID-19. Therefore, you are responsible to pay the allowed amount of $93.86, which is less than the $160 copayment. You received an ultrasound on May 11, 2020. Ultrasound copayments are not waived due to COVID-19. Therefore, you are responsible to pay the allowed amount of $93.86, which is less than the $160 copayment.
The total amount you owe is: $187.72. You have been asked to pay the total copayment amount of $187.72 for ultrasounds. Ultrasounds fall within the 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 ultrasounds provided on May 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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 considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the health plan's denial of LTACH coverage should be overturned. You are currently undergoing treatment at an ACH for CoViD-19. You were intubated/ventilated and subsequently received a tracheotomy. You remain on a ventilator and are being managed by an internist. The internist believes that you are appropriate for LTACH and the hospital points out that they do not have a pulmonologist on staff. You are in need of ongoing intensive care unit (ICU) level care, ventilator management and ventilator weaning, which is likely to be prolonged. As such, transfer to a facility that can provide services which are not currently available is medically necessary and reasonable.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 been met.Therefore, we decided that the Plan has to pre-approveLTACH services.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forfacility charges (G0463) applied to provider visits on September 21, 2020, and October 7, 2020.You asked the Plan to waive the copayment forfacility charges. You say that you were already charged a copay for the office visit.The Plan denied your request. The Plan says this provider is a facility-based provider and will always bill for both professional services (the visit with the provider) and the use of the facility where the provider practices. In this case, the office visit was in an outpatient hospital setting. Outpatient hospital services have a $20 copayment.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 copayment for outpatient hospital services. You have been asked to pay a $20 copayment for facility charges. The office visits with these facility-based providers occurred in an outpatient hospital facility, which falls within the Outpatient Hospital Services benefit category. This meansthat 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 forfacility charges (G0463) applied to provider visits on September 21, 2020, and October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe repair of nasal vestibular stenosis provided on March 28, 2019.You asked the Plan to waive the coinsurance forthe repair of nasal vestibular stenosis. You say that you disagree with the charges because you received a bill over two years later.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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.You received the repair of nasal vestibular stenosis on March 28, 2019. The total allowed amount is $4,655.44 and 20% of that is $931.09.  You have been asked to pay the total coinsurance amount of $931.09 for the repair of nasal vestibular stenosis. The repair of nasal vestibular stenosis 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 coinsurance forthe repair of nasal vestibular stenosis provided on March 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device provided on June 5, 2020.You askedthe Plan to pay fora pneumatic compression device (E0675). You say that the device was provided at the request of the physician.The Plan denied your request. The Plan says the device was used for intra-operative and post-operative prophylaxis.The Planfollows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.We looked at the file and Medicare rules. Based on this information we decidedthat Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the cone beam CT (D0380) provided on August 25, 2020.You asked the Plan to pay forthe dental services. You say that you were experiencing pain in your lower left jaw. You say that you went to your regular dentist who could not determine the exact tooth that was causing the pain. You say that he sent you to an endodontist. You also say that the endodontist had to do an x-ray to determine which tooth was causing your pain.The Plan denied your request. The Plan says limited oral evaluation is covered once per plan year. The Plan says the frequency limit for this service has been exceeded. The Plan also says that cone beam CT is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for this service that you received on June 16, 2020. Additionally, cone beam CT is not listed as a covered service.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the cone beam CT (D0380) provided on August 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgery to place a Vertiflex Superion device (CPT Code(s): 22869 and 22870).
You asked the Plan to pre-approve the services. You say that the services are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has mild to moderate spinal stenosis at 3 lumbar levels, and would not meet FDA indications. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is imaging evidence of spondylolisthesis with no discussion of spinal instability (or lack thereof) on flexion/extension films. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical condition. 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 the surgery to place a Vertiflex Superion device (CPT Code(s): 22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe diagnostic imaging procedure provided on May 28, 2019.You asked the Plan to waive the coinsurance forthe diagnostic imaging procedure. You say that no one warned you about what you should expect to pay. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees inclear, 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 diagnostic tests and procedures. You have been asked to pay $74.32 whichis 20% of the allowed amount for the diagnostic imaging procedure. The allowed amount is $371.62. ($371.62 x 20% =$74.32). The diagnostic imaging procedure falls within the "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 coinsurance forthe diagnostic imaging procedure provided on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided from August 21, 2020, through August 31, 2020. You asked the Plan to waive the copayment for the specialist services. You say that you should not have to pay three (3) copayments for one (1) hearing exam. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Medical records were obtained from the provider's office for each date of service. The medical records indicate that you were seen in the office on August 5, 2020, regarding your complaint of progressive hearing loss. During this visit, an audiogram was suggested. Also in the records it shows that on August 21, 2020 was for an audiogram, and your visit on August 31, 2020, was in regard to your complaint of hearing loss, and to review the audiogram results from the audiogram performed on August 21, 2020, and to compare the results with previous audiogram results you had in 2014 and 2017. The health plan contract says that enrollees must pay a $50 copayment for each specialist visit for Medicare covered service. 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 specialist services provided from August 21, 2020, through August 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal x-ray (72020-59) provided on September 3, 2020. You asked the Plan to pay for a spinal x-ray. You say that these procedures were performed for different indications. The Plan denied your request. The Plan says the use of modifier 59 is not appropriate and 72020 is bundled in 72082. The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 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 a spinal x-ray. Our reviewer says that the use of this code and modifier is not supported. Our physician reviewer found the provider billed Current Procedural Terminology (CPT) 72082 Radiologic examination, spine entire thoracic and lumbar, including skull, cervical and sacral spine if performed, and Current Procedural Terminology (CPT) 72020 Radiologic examination, spine and pelvis for the same date of service. CPT 72020 would be included with CPT 72082 and would not be appropriate to report separately with modifier 59. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a spinal x-ray (72020-59) provided on September 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drugs or medicaments dispensed in the office for home use (D9630) provided on August 27, 2020.You asked the Plan to pay forthe drugs or medicaments. You say that the procedure was done in the office, and you were not sent home with any medication.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.Medicare generally does not cover dental services. However, thePlan 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 forthe drugs or medicaments dispensed in the office for home use (D9630) provided on August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist x-ray provided on September 15, 2020 by an out of network provider.You asked the Plan to pay forthe wrist x-ray (73110). You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service 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 forthe wrist x-ray provided on September 15, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray provided by a participating specialist on October 8, 2020.You asked the Plan to waive the copayment foran x-ray. You say that you had this done at your doctor's office. You say that you should have a $0 copayment.The Plan denied your request. The Plan says the correct copayment has been applied.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 $50 copayment for outpatient diagnostic tests/in-network/basic radiology/specialist's office. You have been asked to pay $22.38 which is less than your copayment amount of $50 for an x-ray. The physician that provided these services is a specialist; therefore, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/in-network/basic radiology/specialist's office 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 foran x-ray provided by a participating specialist on October 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on August 7, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.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 August 7, 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 forthe ambulance services provided on August 7, 2020.