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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429,
A0425) received March 13, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that it was an
emergency and your family dialed 911 because they thought you would pass out. The Plan denied your request.
The Plan says the correct cost share applied to the claim.
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 $325
copayment for Ambulance Transportation.
You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation
falls within the Ambulance Transportation 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 ambulance transportation (A0429, A0425) received March 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of care with an out of network (OON) provider.

You asked the Plan to pre-approve the continuation of care with an OON provider. You say that the enrollee has been seeing this OON provider since 2013. You say that the surgery has been approved and question how the pre-op visit is being denied. The Plan denied your request. The Plan says they have in-network providers who can supply the care needed.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 pre-approve the continuation of care with an OON provider. Our reviewer says that the criteria for OON care have not been met. Our physician reviewer found the enrollee is not currently receiving any active treatment and/or medical management of his condition that makes it medically necessary to continue care with the out-of-network provider as requested. There is not anything unique about this enrollee's condition that would make it medically necessary for him to continue care with the out of network provider. The plan has shown that they have in-network specialists who have qualifications and expertise necessary to meet the current medical standards of care required for treatment of the enrollee's condition. This enrollee's medical management and/or follow-up care can be safely transitioned to an in-network specialist 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 the continuation of care with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of care with an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the comprehensive oral exam
(D0150) and the panoramic x-ray (D0330) provided on March 11, 2021.

You asked the Plan to waive the cost share amount for the dental services. You say that you did not want to go
back to the original dentist due to medical reasons. You say that you should have been covered to have another
oral exam with a new dentist. You also say that you were not informed that this was not going to be covered, or
that you should contact the plan for a pre-estimate or coverage information. The Plan denied your request. The
Plan says 1 comprehensive oral exam is covered every 36 months. The Plan says that the frequency limit has
been exceeded. The Plan also says that there is a 20% coinsurance for panoramic x-rays.

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 exam is listed
as covered, the frequency limit has been exceeded. The record shows that the Plan paid for the comprehensive
oral exam that you received on January 6, 2020. Additionally, the panoramic x-ray processed correctly with the
20% coinsurance applied. Therefore, we decided that the Plan does not have to waive the cost share amount for
the comprehensive oral exam (D0150) and the panoramic x-ray (D0330) provided on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 22, 2020.

You asked the Plan to pay for the ambulance services. 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 November 22, 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 for the ambulance services provided on November 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are 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 not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the medical eye exam provided on March 12, 2021.

You asked the Plan to reduce the copayment for the medical eye exam. You say that you only went for a routine eye exam and paid a $15 copayment. You say you should not be billed any more. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $40 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. 

You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows medical conditions such as dry eye syndrome, cataracts, and posterior vitreous detachment were addressed in addition to the routine eye exam.

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 reduce the copayment for the medical eye exam provided on March 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on October 26, 2020.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425). You say that the ambulance services were medically necessary. The Plan denied your request. The Plan says there is no documentation to support why the enrollee could only be transported by a stretcher and why an ambulette or a wheelchair van would endanger the enrollee's health.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425). Our reviewer says that the ambulance services were not medically reasonable and necessary. Our physician reviewer found the enrollee was a then, 51-year-old male who was brought to the emergency room October 25, 2020 for scrotal pain. His catheter was replaced, and he was discharged to home via ambulance on October 26, 2020. He transferred from bed to stretcher by sliding himself. On arrival to his residence, he got off the stretcher and walked into his home. Although he had a history of recent COVID-19 infection, the medical necessity requirements for coverage of ambulance services have not been changed. There was no documentation to support why the enrollee could only be transported by a stretcher and why an ambulette or a wheelchair van would endanger the enrollee's health. The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport on October 26, 2020 was medically reasonable and necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport
(A0428, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on October 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided by a Licensed Clinical Social Worker (LCSW) on January 6, 2021.

You asked the Plan to pay for office visit. You say that this service was denied for non-coverage, however the Plan has out-of-network benefits. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that certified social worker providers are not eligible to participate in Medicare. 

We looked at the file and Medicare rules. This provider is not eligible to participate in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided by a Licensed Clinical Social Worker (LCSW) on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (v2200, V2784, V2781, V2744) purchased on October 8, 2020.

You asked the Plan to pay for the eyeglasses. You say that you were told by the provider that you needed new glasses and they would cost about $600. You went back after a few weeks and requested the total cost with financial aid. You were granted this aid and received the glasses for $260, and now you are requesting routine eyewear reimbursement for $200 per the Plan's contract. The Plan denied your request. The Plan says your benefits for routine eyewear have been exhausted and no additional payment can be made.

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 up to $200 per year for routine eyewear.

We looked at the file and the Plan's rules. Documentation shows that you previously received eyeglasses on September 1, 2020, for which the Plan paid $200. Therefore, when you purchased eyeglasses again on October 8, 2020, your allowance benefit had been exhausted. 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 (v2200, V2784, V2781, V2744) purchased on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies/materials needed due to a Public Health Emergency (PHE) for services provided on January 7, 2021, billed with code 99072.
You asked the Plan to pay for the additional supplies/materials as billed. You say that these services do not require modifier -59 to be separately paid. The Plan denied your request. The Plan says it was decided to make payment for code 97530; however, code 99072 is bundled and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99072 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this is bundled into payment for other services provided on the date of service. Based on this information, we
decided that Medicare rules for coverage of the additional supplies/materials as billed have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies/materials needed due to a Public Health Emergency (PHE) for services provided on January 7, 2021, billed with code 99072.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on February 8, 2021.

You asked the Plan to waive the deductible for the office visit. You say that the amount charged for the visit is too high for the appointment you had. You say that your insurance has no deductible and you are required to pay a copayment of $40 or $50. The Plan denied your request. The Plan says the deductible applied correctly.

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 your combined (in-network and out-of-network) deductible is $198. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services.

The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $198 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on February 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on February 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (78452) provided on March 12, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered advanced radiology service.

You have been asked to pay a $150 copayment for the advanced radiology service provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (78452) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on March 22, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says you exceeded the limit of one routine eye exam every year.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on March 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary for the member to regain strength and functional quality of life. The Plan denied your request. The Plan says that LTACHs do not provide clinical advantage over non-LTACH acute care hospitals.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve a laminotomy. We decided that the Plan does not have to pre-approve insertion of Coflex devices.

You asked the Plan to pre-approve a laminotomy. You say that the requested services are a medical necessity for the enrollee. The Plan says that the requested treatment is experimental and investigational.

We decided that the Plan has to pre-approve a laminotomy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a laminotomy. Our reviewer says that the enrollee meets criteria for a decompressive laminotomy. 

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 laminotomy have been met. Therefore, we decided that the Plan has to pre-approve a laminotomy (63030, 63035).

We also decided that the Plan does not have to pre-approve insertion of Coflex devices.

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 insertion of Coflex devices. Our reviewer says that Coflex is not needed. Our physician reviewer found that the Coflex device remains experimental and is not needed as there is no documented segmental instability. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of Coflex devices have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of Coflex devices (22867, 22868).

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.