Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological medical examination and evaluation (92012) provided on April 5, 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 $35 copayment for each in-person specialist visit. You have been asked to pay a $35 copayment for the specialist visit 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 ophthalmological medical examination and evaluation (92012) provided on April 5, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says that the rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that SNF care is medically necessary and reasonable. Our physician reviewer found you are a 92-year-old female with a past medical history of breast cancer, atrial fibrillation, asthma, heart failure, osteoporosis and osteoarthritis who presented to the acute hospital on July 26, 2021, with symptomatic left knee arthritis pain. You underwent an uncomplicated left knee total arthroplasty on July 26, 2021. Based on the medical records provided there is documentation that you require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment due to your hypoxia and new supplemental oxygen therapy. In addition, you also require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment due to your functional limitations after the knee replacement. These services are required on a daily basis for oxygen monitoring and functional decline. In conclusion, based on the records provided you do require the services on an inpatient in a skilled nursing facility setting for what would be expected to be a short stay to then transition to home with home health 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Cystourethroscopy (81003, G0463, 52000) provided April 7, 2021.

You asked the Plan to waive the copayment for the Cystourethroscopy. You say that the copayment should be limited to the $25 specialist copayment. 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 $325 copayment for Outpatient Hospital Services. 

You have been asked to pay a $325 copayment for the Cystourethroscopy. The Cystourethroscopy falls within the Outpatient Hospital Services 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 Cystourethroscopy (81003, G0463, 52000) provided April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) colonography (74263).

You asked the Plan to pre-approve the CT colonography. You say that you are appealing the denial of the CT colonography. Your mother died at 78 from pancreatic cancer that had originated as colon cancer that had metastasized. The Plan denied your request. The Plan says computed tomographic colonography is not covered by Medicare as a colorectal cancer screening test.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) colonography (74263).
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 this could jeopardize the enrollee's chances for home/community discharge. 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 coronary artery bypass grafting, a heart attack and heart failure. Medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a joystick for an expandable controller (K0108), seat elevator (E2300) and attendant control (E2331).

You asked the Plan to pre-approve a joystick for an expandable controller, seat elevator, and attendant control. You say that this request is medically necessary. The Plan denied your request. The Plan says these items are noncovered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is statutorily non-covered. Medicare rules also say that K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. Medicare rules also say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered 

We looked at the file and Medicare rules. In this case, the power seat elevation feature is noncovered. In addition, K0108 has been billed as a feature of an expandable controller and is not eligible for coverage. Finally, an attendant control is non-covered when provided in addition to a beneficiary-operated drive control system. Based on this information, we decided that Medicare rules for coverage of a joystick for an expandable controller, seat elevator, and attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve a joystick for an expandable controller (K0108), seat elevator (E2300) and attendant control (E2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve resin-based composite - one surface, posterior (CPT code D2391).

You asked the Plan to pre-approve the dental services. You say that you cannot afford a big bill for the services. The Plan denied your request. The Plan says preventative dental services such as cleanings, routine dental exams and dental x-rays are covered benefits. The Plan states the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve resin-based composite - one surface, posterior (CPT code D2391).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on August 18, 2020.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. 

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on August 18, 2020.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra-wide hospital bed with weight capacity greater than 350 pounds (E0303).
You asked the Plan to pre-approve a heavy duty hospital bed. You say that the enrollee needs a new hospital bed as the current one is broken. The Plan denied your request. The Plan says the requested item cannot be covered in this case because the enrollee's weight is fewer than 350 pounds.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy duty hospital bed have not been met. Specifically, the Plan attests that the enrollee's weight is fewer than 350 pounds. The case record does not contain any information to dispute the Plan's assertion. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra-wide hospital bed with weight capacity greater than 350 pounds (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99202, 97014) provided to you on March 19, 2021.
You asked the Plan to pay for the services. You say that the services should be covered. The Plan denied your request. The Plan says these services are not covered.
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 chiropractic services (99202, 97014) provided to you on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 2020 Wellness Bucks during 2021.

You asked the Plan to pay for the 2020 Wellness Bucks. You say that you were not educated on the benefits properly. The Plan denied your request. The Plan says 2020 Wellness Bucks cannot be reimbursed at this date.

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 $150 will be paid per year towards the Wellness Bucks benefit. 

You are requesting use of the 2020 benefit to cover the cost of fitness equipment. Wellness Bucks can only be used in the designated year. Reimbursement requests for 2020 Wellness bucks must be submitted by March 31, 2021. It is past that date. Therefore, we decided that the Plan does not have to pay for 2020 Wellness Bucks during 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99308) provided on November 24, 2020 to December 15, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician services (99308) provided on November 24, 2020 to December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GeneSight psychotropic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says testing must be FDA-approved, or of analytical and clinical validity.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no confirmed diagnosis of major depressive disorder, recurrent, severe, with no PHQ-9 reported. The enrollee has not responded to at least one other medication which is noted in the record above as well as being on multiple medications for her condition which increase the risk of adverse effects as noted again. The ordering psychiatrist must be board certified in psychiatry or neuropsychiatry. The ordering physician for this test is not boarded in psychiatry or neuropsychiatry.
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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve GeneSight psychotropic testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on February 24, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) the unspecified endodontic procedure, by report (D3999), the treatment of root canal obstruction; non-surgical access (D3331) or pay an additional amount for the endodontic therapy, molar tooth (excluding final restoration) (D3330) and the retreatment of previous root canal therapy - premolar (D3347).

You asked the Plan to pay for the dental services. You say that the Plan should pay for these services. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 unspecified endodontic procedure (D3999) and the treatment of root canal obstruction; non-surgical access (D3331) are not among those covered under this benefit. The Plan limits coverage of bitewing x-rays to two procedures every year. The Plan has submitted evidence that the Plan covered two bitewing x-rays on February 22, 2020. You are responsible for any additional bitewing x-rays beyond the first two. The Plan provides coverage for endodontic therapy (D3330) and the retreatment of previous root canal therapy (D3347) with 10% coinsurance. The provider charged $477 for the endodontic therapy and you owe 10% coinsurance for this service ($47.70). The provider charged $405 for the retreatment of the root canal and you owe 10% coinsurance for this service ($40.05). The correct cost share amount has applied to these claims.Therefore, we decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) the unspecified endodontic procedure, by report (D3999), the treatment of root canal obstruction; non-surgical access (D3331) or pay an additional amount for the endodontic therapy, molar tooth (excluding final restoration) (D3330) and the retreatment of previous root canal therapy - premolar (D3347) received September 23, and September 25, 2020.