Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites of two surfaces (D2392 x2) and resin-based composite of three surfaces (D2393) provided on December 8, 2020.
You asked the Plan to pay for the resin-based composites. You say that you would like to know why these services were denied. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 two resin-based composites of two surfaces (D2392 x2) and resin-based composite of three surfaces (D2393) provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0676) provided on September 2, 2020.
You asked the Plan to pay for an intermittent limb compression device. You say that the requested item was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that an intermittent limb compression device was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0676) provided on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided July 1, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 80307 & G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service shown in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0483) provided July 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve the home health services. You say that you are diabetic and have multiple ulcers on your legs that you are not able to take care of yourself due to your hernia. You feel that it is necessary to have wound care provided in the home health setting. The Plan denied your request. The Plan says you are not considered to be homebound or confined to your home. As Medicare home health benefit criteria are not met, this request has been denied.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy when the enrollee is homebound based on the Medicare definition. 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 home health services. Our reviewer says that the documentation does not support the need for home health skilled nursing visits. Our physician reviewer found documentation on a 12/14/20 note patient does not have pain affecting ability to walk. He can very easily do his shopping, get around his house, and perform daily living activities. The records do not show that home health skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The records also do not show that the patient is homebound; therefore, the criteria for home health services has not been 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 the home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Durolane. Our reviewer says that Durolane (J7318) is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 2D oral or facial photographic images (D0350) provided on September 24, 2020.
You asked the Plan to pay for the dental services. You say that you are not financially able to pay for these charges. The Plan denied your request. The Plan says comprehensive oral evaluation is limited to once every 3 plan years. The Plan says that the frequency limit has been exceeded. The Plan also says that 2D oral or facial photographic images is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for this service that you received on June 20, 2020. Additionally, the 2D oral or facial photographic images is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 2D oral or facial photographic images (D0350) provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on May 15, 2020.

You asked the Plan to pay for the office visit. You say that you submitted the medical report and the referral. You say that the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization 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 requested provider in this case is not a network provider with the Plan. 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 office visit provided by an out-of-network provider on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for talk therapy and fMRI with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that there is a contractual requirement to stay in-network. The Plan denied your request. The Plan says the plan does not offer the requested services.
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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is unclear how the use of fMRI findings would alter or change the treatment of the enrollee. The enrollee is being treated for anxiety disorder and major depressive disorder, and is not taking any medication. This is not considered an emergent 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral for talk therapy and fMRI with an out-of-network provider.
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 IRF services are 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 the medical record supports a need for physical or occupational therapy, however
there is no documented need for intensive inpatient rehabilitation 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and nausea associated with chemotherapy. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on July 7, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on July 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for endoscopic procedures (31628, 31624, 31623) provided on December 2, 2020.

You asked the Plan to pay for endoscopic procedures. You say that these procedures should be covered. The Plan denied your request. The Plan says this claim processed correctly.

The Plan must follow Medicare rules. Medicare rules say that if Field 21 of the Medicare Fee Schedule Database (MFSDB) contains an indicator of "3," and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy.

We looked at the file and Medicare rules. The record shows that multiple endoscopic procedures with a MFSDB Field 21 indicator of 3 were billed. The Plan has paid codes 31653, 31629, and 31627 according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional endoscopic procedures at issue have not been met. Therefore, we decided that the Plan does not have to pay for endoscopic procedures (31628, 31624, 31623) provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950 x 2), the retainer crowns (D6742 x 2) and the pontic (D6242) provided on December 3, 2020.
You asked the Plan to pay for the dental services. You say that you were advised there would be a $400 copayment for these services. You say that you were then told that you owed an additional $1,801. You say that a plan representative advised that you owed $400 for tooth # 19, and $250 each for teeth # 18 and 20. You also say that you no longer wish to continue seeing this dentist. The Plan denied your request. The Plan says there is a $400 copayment for crowns. The Plan says there is a $50 copayment for core build up. The Plan also says that the claim was processed correctly.
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 the services are listed as covered, there are copayments that apply to these services.
CPT Code - Tooth # - Copayment
D2950 - 18 - $50
D6752 - 18 - $400
D6242 - 19 - $400
D2950 - 20 - $50
D6752 - 20 - $400
TOTAL: $1300
These are a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the core build up (D2950 x 2), the retainer crowns (D6742 x 2) and the pontic (D6242) provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on October 8, 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 an office visit (99213) provided September 29, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was a pre-op visit and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the specialist visits 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 an office visit (99213) provided September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the bladder lesion treatment and BCG injection provided on November 17, 2020 and November 24, 2020.
You asked the Plan to waive the cost share for the bladder lesion treatments and BCG injections. You say that you were previously charged $75 per treatment and now your charge after insurance is $278.35 per visit. The Plan denied your request. The Plan says the cost share 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 $250 copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center and 20% coinsurance for each Medicare-covered Part B drug from an in-network provider. You have been asked to pay a total of $556.70 for the bladder lesion treatment and BCG injection.
Date of Service
Service
Allowed Amount
Standard Cost
Member Liability
November 17, 2020
Bladder Treatment
$255.80
$250
$250
November 17, 2020
BCG Injection
$141.74
20%
$28.35
November 24, 2020
Bladder Treatment
$255.80
$250
$250
November 24, 2020
BCG Injection
$141.74
20%
$28.35
TOTAL:
$556.70
The bladder lesion treatment falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The BCG injection falls within the "Medicare Part B prescription drugs" 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 cost share for the bladder lesion treatment and BCG injection provided on November 17, 2020 and November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0482) provided on September 8, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration because this testing was time sensitive and medically necessary. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the claim was submitted with a laboratory place of service code while the documentation submitted indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0482) provided on September 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 21, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the enrollee was in hospice care on this date of service.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 21, 2020.