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

We decided that the Plan does not have to pay for the dental bridge (D6240, D6740) you received on August
11, 2020.
You asked the Plan to pay for the bridge. The Plan denied your request. The Plan says these services are not
covered.
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 services are not among
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in
the Evidence of Coverage. Dental codes D6240 and D6740 are not listed, and therefore are not covered.
Therefore, we decided that the Plan does not have to pay for the dental bridge (D6240, D6740) you received on
August 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that The Plan denied your request. The Plan says the enrollee requires custodial care assistance.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee is weak and unsteady. She is walking about 5 feet with moderate assistance with a walker and is stand-by assist for transfers and total assist for some activities of daily living. Therapy notes do not document any improvement in functional status. There is no report of any acutely unstable medical conditions. There are no identifiable skilled nursing service needs. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested admission 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 not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital following
surgery for a perforated esophagus. The enrollee is not intubated/ventilated. The enrollee does not require
services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan.
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says your plan was not the primary insurance carrier in this case.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frames you received on November 20, 2020.

You asked the Plan to pay for the frames. The Plan denied your request. The Plan says the benefit limit has been reached.

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 these services up to a $200 maximum benefit each year. 

We looked at the file and the Plan's rules. The records show that the Plan has paid $200 toward your eyewear for the 2020 calendar year prior to the frames in question being received. The frames exceed the benefit limit and you are responsible for the cost. Based on this information, we decided that the Plan's rules for coverage of the frames have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass frames you received on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on June 23, 2020.
You asked the Plan to pay for the initial nursing facility care. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 initial nursing facility care provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on July 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon
services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code
12020. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore,
we decided that the Plan does not have to pay for the assistant surgeon services provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750).

You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is not covered.

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 pre-approve a crown (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you have used this surgeon before and would like to use him again. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on November 5, 2020.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams on this date. The Plan denied your request. The Plan says this is 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. In this case, we have confirmed that code 71045 has a bundled relationship with code 32557 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Telephone evaluation and management service by a physician or other qualified health care professional (99442) provided on October 12, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the physician services. You say that you were not required to obtain prior authorization for services. The Plan denied your request. The Plan says the services were rendered by an OON 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 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 Telephone evaluation and management service by a physician or other qualified health care professional (99442) provided on October 12, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay from March 2 through March 14, 2020.

You asked the Plan to waive the copayments for the inpatient hospital stays. You say that the enrollee received continuous care and should not be charged two separate copayments. The Plan denied your request. The Plan says the correct cost share amount was applied to the claims.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $298 copayment per day, for days 1 - 7 for inpatient hospital care, and $0 for days 8 - 90. 

The enrollee has been asked to pay a total of $2086 in copayments ($298 copayment per day, for days 1 - 7 for the inpatient hospital stay. This stay falls within the inpatient hospital care benefit category. In addition, inpatient cost share will begin on day one each time the enrollee is admitted or transferred to a specific facility type. When the enrollee was admitted to the hospital on March 2, 2020 it was considered day one of the inpatient hospital stay. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the inpatient hospital stays.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) you received on September 16, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this is not a covered 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 requested services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Full mouth debridement is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the full mouth debridement (D4355) you received on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on July 20, 2020.
You asked the Plan to pay for the COVID-19 testing.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and ordering physician.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing. have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in Illinois while the member and laboratory are located in Texas. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99203) provided on May 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" is interpreted to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. We looked at the file and Medicare rules. The records show that the enrollee was provided Evaluation and Management services by this provider on November 18, 2019, and November 19, 2019. The requested new patient visit provided less than 3 years after the services in 2019. This means that the enrollee was not considered a new patient for the visit in question. It is inappropriate to bill a new patient visit in this case. 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 pay for the services (99203) provided on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 and the x-ray services coded 71045 provided on September 21, 2020.

You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility and the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 Current Procedural Terminology (CPT) code. In this case, we have confirmed that code the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility services coded 99053 has a status indicator of "B". This means that payment for this service has a bundled relationship with other services and cannot be paid as billed. This code cannot be paid as a separate line item. In addition, code 71045 was billed with place of service 11 (outpatient); however, the documentation supports that the enrollee was inpatient during this date of service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 and the x-ray services coded 71045 provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided January 31, 2020 to February 05, 2020.

You asked the Plan to pay for the acute inpatient level of care. You say that you were told to cancel your other insurance plan and you made sure that the services would be approved by the Plan. The Plan denied your request. The Plan says services was received before this healthcare plan's coverage began.

The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, the new Plan is not responsible for inpatient hospital care until after the date of discharge. 

A different health plan was the Plan of record at the time of the inpatient stay at issue in this appeal began. This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided January 31, 2020 to February 05, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for dental restorations (D2330, D2331) provided from September 15, 2020, to October 1, 2020.
You asked the Plan to pay the full cost for dental restorations. You say that this should be covered. The Plan denied your request. The Plan says this processed with the correct cost-sharing.
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. The Plan covers dental restorations with a $100 deductible and a 20% coinsurance after the deductible is met. We looked at the file and the Plan's rules. The record shows that you have been asked to pay $100 towards the deductible and a $17.86 coinsurance (20% of the $88 allowed amount of the second restoration). This means you have been asked to pay the correct amount based on your contract. Therefore, we decided that the Plan does not have to pay the full cost for dental restorations (D2330, D2331) provided from September 15, 2020, to October 1, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Paclitaxel protein bound particles, and Gemcitabine HCL.
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says that the requested regimen is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 requested drugs. Our physician reviewer found that the requested use of Paclitaxel protein bound particles, and Gemcitabine HCL is not FDA-approved for the enrollee's diagnosis. However, the use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The enrollee received FOLFIRINOX as neoadjuvant therapy, but had toxicities and could not continue in the adjuvant setting. Gemcitabine/abraxane is an alternative to FOLFIRINOX, and would be an acceptable alternative in the adjuvant setting. According to the ASCO guidelines for locally advanced, unresectable pancreatic cancer, induction with at least 6 months of initial systemic therapy (with a combination regimen) is generally recommended in patients with ECOG performance status of 0 or 1, a favorable comorbidity profile, a preference for aggressive therapy, and a suitable support system; there is no clear evidence to encourage one regimen over another. The paclitaxel (protein bound)-gemcitabine combination regimen (recommended in the metastatic setting) has not been evaluated in randomized, controlled studies for locally advanced, unresectable pancreatic cancer, but may be an option in patients with good performance status. If disease progression occurs, treatment according to guidelines for metastatic pancreatic cancer should be offered. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 the requested drugs have been met. Therefore, we decided that the Plan has to pre-approve Paclitaxel protein bound particles, and Gemcitabine HCL.
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.