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

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on March 31, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you had an annual wellness exam. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for physician/practitioner services/PCP. 

You have been asked to pay a $5 copayment for an office visit. Evidence was provided that shows that additional services were provided during your annual wellness exam. When additional services are provided that go beyond an annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied. An office visit falls within the physician/practitioner services/PCP 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 provided by a participating provider on March 31, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable
venous access device (36591) performed on February 16, 2021.
You asked the Plan to waive the copayment for a collection of a blood specimen from an implantable venous
access device. You say that you have never before had to pay a copayment for blood draws. The Plan denied
your request. The Plan says that the correct copayment was applied.
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 enrollees must pay a $0 copayment for laboratory tests.
The Plan says you must pay a $110.73 copayment for a collection of a blood specimen from an implantable
venous access device. Based on the Plan contract, however, you cannot be asked to pay more than a $0
copayment for a collection of a blood specimen from an implantable venous access device. Therefore, we
decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable
venous access device (36591) performed on February 16, 2021.
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 pay for a replacement of a gastrostomy tube (43762) performed on August 16, 2020.
You asked the Plan to pay for a replacement of a gastrostomy tube. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the record does not support the service 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. In this case, the CPT Code Manual definition of code 43762 is "Replacement of gastrostomy tube, percutaneous."
We asked our coder 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 a replacement of a gastrostomy tube. Our reviewer says that the service at issue does not meet criteria for billing or reimbursement consideration. Our coder reviewer found that the medical records provided do not include documentation of a replacement of gastrostomy tube, percutaneous, being performed on August 16, 2020; therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a replacement of a gastrostomy tube have not been met. Therefore, we decided that the Plan does not have to pay for a replacement of a gastrostomy tube (43762) performed on August 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this denial is appropriate given the clinical scenario.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not checking blood glucose levels four times a day and is not taking insulin three or more times per day. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.

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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that your 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.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on July 13, 2020.
You asked the Plan to pay for genetic testing. You say that the enrollee meets all of the requirements for coverage of this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the clinical information does not show that the enrollee met the criteria for this testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on July 13, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5257, V5267, A9270) received on February 5, 2021.
You asked the Plan to pay for hearing aids. You say that you want the Plan to reimburse you. The Plan denied your request. The Plan says the items were received from a non-participating provider and are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when services are rendered by an in-network provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257, V5267, A9270) received on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the surgical extraction (D7210) provided from February 16, 2021, to February 17, 2021.
You asked the Plan to pay for the dental services. You say that you paid $277 for the services that you received. You also say that you are being billed for the $98 balance. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan also says that surgical extraction is not listed as a covered service either.
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 limited oral evaluation, periapical x-ray, and surgical extraction are not among those covered under this benefit. You are responsible for the full amount for dental services that are not covered by the Plan.
Service
Billed Amount
Allowed Amount
Plan Paid
Your Responsibility
D0140
$70
$70
$0
$70
D0220
$28
$28
$0
$28
D7210
$257
$257
$0
$257
TOTAL:
$355
The total for the services that you received is $355. $355-$277=$78. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the surgical extraction (D7210) provided from February 16, 2021, to February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia service provided on April 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for anesthesia service. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and there was not a referral from an in-network provider.
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 anesthesia service provided on April 15, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 1, 2020, to December 16, 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 procedure codes S9122 and S9123 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure codes S9122 (home health aide services) and S9123 (home health nursing care have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the home health services rendered from December 1, 2020, to December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are needed to optimize the enrollee's mobility and level of independence prior to returning home. The Plan denied your request. The Plan says that the member's care needs can be met in the skilled nursing facility setting.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of an infected artificial knee joint, sepsis, and pneumonia. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 8, 2021.

You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you want the Plan to reimburse you for the services. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. The Plan says the intraoral complete series of radiographic images is a covered benefit, but you have exceeded the frequency limit of one every 5 years.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 19, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on March 10, 2021 by an OON provider.

You asked the Plan to pay more for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you were advised that 25% of these services would be covered. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the difference between the billed amount and allowed amount, plus the 50% coinsurance for each service when the services are received OON. Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on March 10, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion surgery.
You asked the Plan to pre-approve the Vertiflex Superion surgery. You say that the records provided support the need for the Vertiflex procedure. The Plan denied your request. The Plan says the requested service is experimental and investigational.
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 Vertiflex Superion surgery. Our reviewer says that the Vertiflex Superion surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic lumbar radiculopathy with neurogenic claudication. The record indicates that imaging has demonstrated severe spinal stenosis at L4-L5, the level requested for treatment. 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 Vertiflex Superion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up referral with an out-of-network orthopedic
surgeon.
You asked the Plan to pre-approve the referral. You say that the in-network redirect would not be safe and
would serve little to no purpose. The Plan denied your request. The Plan says there are no guidelines requiring
the same surgeon for follow-up.
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 referral is not considered medically reasonable and necessary in this case. Our physician reviewer
found this is a routine total hip procedure surgery. There is no medical need for an out-of-plan referral.
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 follow-up referral with an out-of-network orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on March 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the annual wellness visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 annual wellness visit (G0439) provided on March 1, 2021, by an out-of-network (OON) provider.