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

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on December 30, 2020.

You asked the Plan to pay for an electrocardiogram. You say that this code is supported. The Plan denied your request. The Plan says this procedure is not documented.

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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

We find that CPT code 93010 is not supported in the medical record. Specifically, the submitted medical records do not document an electrocardiogram being performed. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The file shows that the services were billed with POS code 81 for an independent laboratory but the enrollee was under inpatient status for the date of service at issue. POS code 21 should be billed for services rendered to a registered inpatient. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services were 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on September 4, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because
it was part of your COVID-19 treatment. 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 $150
copayment for CT scans.
You have been asked to pay a $150 copayment for a CT scan. A CT scan 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 copayment
for a CT scan provided on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on January 15, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says with
limited exceptions, while the member is enrolled in the plan, the member must use network providers to get
medical care and services. The only exceptions are emergencies, urgently needed care when the network is not
available (generally, when out of the area), out-of-area dialysis services, and cases in which the plan authorizes
the use of out-of-network providers.

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
physical therapy 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 physical therapy services provided on January 15,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. The patient has not tried and failed the zoledronic acid and they do not have a history of osteoporosis fracture. There is no documentation provided indicating that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2715, V2750, V2781, V2784) purchased on October 19, 2020.
You asked the Plan to pay for the eyeglasses. You say that you had a drastic change in your vision after you purchased glasses in May of 2019 and needed a new prescription by the end of 2020. You also say you have a limited income and need help with this cost. The Plan denied your request. The Plan says you used your benefit for eyewear in May of 2019. The Plan will only provide up to $200 for new lenses and frames every 2 years.
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 covers one pair of eyewear (contacts or lenses and frames) for up to $200 once every two years.
We looked at the file and the Plan's rules. You had purchased eyewear less than two years prior to the date in
question. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2715, V2750, V2781, V2784) purchased on October 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on March 25, 2020 by
an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were rendered in good faith. The
Plan denied your request. The Plan says authorization for out-of-network services was not obtained.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the psychotherapy services provided on March 25, 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 surgical extraction (D7210), the periodontal maintenance (D4910), the gingival irrigation (D4921 x 4), the adjunctive pre-diagnostic test (D0431), and the topical application of fluoride varnish (D1206) provided from November 19, 2020, to November 30, 2020.

You asked the Plan to pay for the dental services. You say that the paperwork was not filled out properly. You say that it was not submitted to the proper department. The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that the extraction, periodontal maintenance, gingival irrigation, pre-diagnostic adjunctive testing, and fluoride varnish are not listed as covered dental services.

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 surgical extraction (D7210), the periodontal maintenance (D4910), the gingival irrigation (D4921 x 4), the adjunctive pre-diagnostic test (D0431), and the topical application of fluoride varnish (D1206) provided from November 19, 2020, to November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were not aware the company was not in-network. The Plan denied your request. The Plan says the services were received 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on November 10, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI of the spinal canal and its contents.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the member has tried medication with little relief. The Plan denied your request. The Plan says the documentation does not include any evidence of conservative treatment.
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 the MRI. Our reviewer says that an MRI study of the lumbar spine is not medically necessary at this point in the care of this enrollee. Our physician reviewer found no treatment modalities have been utilized such as pain management and physical therapy. Furthermore, the member has no alarming signs or symptoms for which an MRI would be necessary for further evaluation. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI of the spinal canal and its contents.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, ultrasound therapy services, therapeutic procedure, manual therapy techniques, and the electrical stimulation services provided on December 8, 2020 and December 10, 2020.

You asked the Plan to pay for the office visit, ultrasound therapy services, therapeutic procedure, manual therapy techniques, and the electrical stimulation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit, ultrasound therapy services, therapeutic procedure, manual therapy techniques, and the electrical stimulation services provided on December 8, 2020 and December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing care services provided on November 27, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the enrollee was in a nursing home and authorization was not needed. The Plan denied your request. The Plan says authorization for out-of-network services was not obtained.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available to provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the nursing care services provided on November 27, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 11, 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 referring provider 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 laboratory services provided on March 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on November 1, 2020, to November 30, 2020.

You asked the Plan to waive the copayment for a skilled nursing stay. You say that you already met your out-of-pocket maximum. 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 $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing facility.

You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-30 for a skilled nursing stay. The total amount you are being asked to pay is $543.82 which is less than your copayment amount of $1,602 ($178 x 9 days= $1,602) due to reaching your out-of-pocket maximum. A skilled nursing stay falls within the skilled nursing 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 copayment for a skilled nursing stay provided by a participating provider on November 1, 2020, to November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7140), the panoramic x-ray (D0330), and the limited oral evaluation (D0140) provided on January 25, 2021.
You asked the Plan to reimburse you for the dental services. You say that this was an emergency. You also say that you had to have a tooth extracted. The Plan denied your request. The Plan says extraction is not listed as a covered service. The Plan says that panoramic x-ray is not listed as a covered service. The Plan says that limited oral evaluation is not listed as a covered service either. The Plan also says there is no record that you contacted them prior to the date of service to verify benefits and provider eligibility.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the extraction (D7140), the panoramic x-ray (D0330), and the limited oral evaluation (D0140) provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on March 19, 2020.

You asked the Plan to pay for the core buildup. You say that you believe you were billed for unnecessary services. The Plan denied your request. The Plan says you had met your annual maximum benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $2,000 allowance for covered dental services. The contract says that you are responsible for 100% of charges beyond the $2,000 allowance. The record shows that you met the annual maximum benefit while processing this claim for the March 19, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required provided on March 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening (G0297) provided to the enrollee on June 23, 2020.

You asked the Plan to pay for this service. You say that this imaging was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for the low-dose CT scan for lung cancer screening performed on June 23, 2020. The QIC determined that the submitted medical records indicated that the enrollee is a current smoker with a 30-pack-year history, indicating that the criteria for coverage were met. Therefore, it was decided that the Plan had to pay for a low dose computed tomography scan for the lung cancer screening provided on June 23, 2020. The Plan requested a reopen and argued that neither of the diagnosis codes provided indicated that the enrollee is or was a smoker. Our Medical Director has concluded that the Plan is correct in this case. The documentation in the case file does not contain documentation of the enrollee's actual pack-year smoking history. The documentation also does not support that the enrollee was asymptomatic, was a current smoker or had quit smoking within the previous 15 years and had a tobacco smoking history of at least 30 pack-years. Medicare coverage criteria were not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for a low dose computed tomography (LDCT) scan for lung cancer screening (G0297) provided to the enrollee on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), the prophylaxis (D1110), and the periodic oral evaluation (D0120).

You asked the Plan to pay for the dental services (D0220, D1110, D0120). You say that you were never told by your dental provider that they were no longer in-network. The Plan denied your request. The Plan says you can get care from an out-of-network dental provider, but you may pay more.

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 payment is in excess of that covered under this benefit. The Plan has agreed to pay 100% of the allowed costs for the services at issue. You are responsible for the difference between the plan's allowed amount and the amount charged by the out-of-network provider ($50 total). Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), the prophylaxis (D1110), and the periodic oral evaluation (D0120).