Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology services provided on December 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the pathology services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.

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. 

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 failed to make a final determination within the allotted time frame. In this case, the Plan has not provided any documentation showing that the Plan had in-network specialist's available to you at the time these services took place. Therefore, we decided that the Plan has to pay for the pathology services provided on December 10, 2020 by an out of network (OON) provider.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient therapy services provided
from October 16, 2020, to December 21, 2020.

You asked the Plan to waive the copayments for the outpatient therapy services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you received outpatient therapy services on the dates of service at
issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

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 $25
copayment for Outpatient rehabilitation services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient
therapy services provided from October 16, 2020, to December 21, 2020. You have been asked to pay a $25
copayment for each of the outpatient therapy services. The outpatient therapy services fall within the
Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct
amounts 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 copayments for
the outpatient therapy services provided from October 16, 2020, to December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cataract surgery (66984) provided on December 2, 2020.

You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share 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 $1,000 deductible, this is the amount you have to pay out of pocket before the Plan will pay their share for your covered medical services. After you pay your $1,000 deductible you pay a $350 copayment for outpatient surgery provided at an ambulatory surgical center or outpatient hospital. 

You have been asked to pay $1,350 ($1,000 deductible + $350 copayment ) for the outpatient surgery 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 cost share for the cataract surgery (66984) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided on January 28, 2021.

You asked the Plan to pay for the office visit services. 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims, using Place of Service (POS) 02 - Telehealth, to indicate they furnished the billed service as a professional telehealth service from a distant site.

We looked at the file and Medicare rules. The services at issue were telehealth services that were not billed with POS 02. Therefore, we decided that the Plan does not have to pay for the office visit services provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), drugs or medicaments dispensed in the office for home use (D9630) and topical application of fluoride varnish (D1206) provided January 23, 2020.
You asked the Plan to pay for the periodontal maintenance, drugs dispensed for home use and fluoride varnish treatment. You say that you would like the services covered. Plan denied your request. The Plan says the drugs dispensed for home use and fluoride varnish are not covered under your benefits. Additionally, the Plan say that since you recently had active periodontal therapy, the periodontal maintenance was not eligible or coverage at the time of 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. The Plan covers the periodontal maintenance no sooner than three months after completion of active periodontal therapy. The Plan does not cover drugs dispensed for home use or fluoride varnish under your benefits. We looked at the file and Medicare rules. The Plan previously covered full mouth periodontal scaling and root planning on December 10, 2019. Based on this information, we decided that the Plan's rules for coverage of the periodontal maintenance have not been met. Though the Plan offers dental benefits in excess of Medicare coverage, drugs dispensed for home use and topical application of fluoride varnish are not among those covered under your benefits. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), drugs or medicaments dispensed in the office for home use (D9630) and topical application of fluoride varnish (D1206) provided January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiology services provided on January 22, 2021.
You asked the Plan to pay for cardiology services. You say that the enrollee evidently required this medical care regardless of whether there was authorization. The Plan denied your request. The Plan says the denial of
payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for cardiology services. Our reviewer says that this service does not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could have foreseen the need for services prior to leaving the Plan's service area. The records submitted do not sufficiently support that these services were medically necessary. It would have been reasonable to delay the services until after the enrollee disenrolled from the Plan on January 31, 2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cardiology services have not been met. Therefore, we decided that the Plan does not have to pay for cardiology services provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup, including any pins when required provided on August 12, 2020 by an OON provider.

You asked the Plan to pay for the crown and core buildup. You say that the enrollee was not aware that services rendered by an OON provider would not be covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because the enrollee's plan does not have OON benefits.

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 enrollee is responsible for 100% of the cost for dental services rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the crown and core buildup, including any pins when required provided on August 12, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the thoracic spine (72146) to be provided by an out of network provider.
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that you have had X-rays and alternative treatments and therefore should be able to get the MRI. The Plan denied your request. The Plan says rules for out of network care have not been met.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.
Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the thoracic spine (72146) to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for computed tomography (CT) imaging services.
You asked the Plan to waive the cost share for imaging services. You say that you do not have the possibility of being able to pay. The Plan denied your request. The Plan says the service is covered by the plan with a coinsurance responsibility.
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 20% coinsurance for complex diagnostic and therapeutic radiology services. The file shows that CT guidance for placement of radiation therapy fields was requested. There is a 20% coinsurance for complex diagnostic and therapeutic radiology services This is 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 computed tomography (CT) imaging 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 enrollee requires daily physician management
and intensive therapies to optimize mobility and strengthening. The Plan denied your request. The Plan says the
enrollee does not require intensive daily therapy.

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 physician reviewer found
that the enrollee was admitted to the acute care hospital for congestive heart failure and a fractured clavicle and
was transferred to a skilled nursing facility where he currently resides. His medical conditions are stable. There
are no complex nursing needs. He does not require treatment by multiple therapies in an intensive rehabilitation
therapy program. He does require physical and occupational therapy, but there is no documented need for an
intensive rehabilitation program.

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 IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested care is a necessity for the enrollee. The
Plan denied your request. The Plan says rules for IRF care have 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 that 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 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. There is not a reasonable
expectation that the 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracellular fluid analysis for lymphedema
assessments.
You asked the Plan to pre-approve the requested services. You say that the device is supported by medical
literature. The Plan denied your request. The Plan says there are not enough studies to show the requested
service is safe and effective to treat lymphedema.
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 requested services. Our physician
reviewer found that the enrollee is status post left simple mastectomy with sentinel lymph node biopsy. She has
lymphedema. The review has determined that the requested device is not indicated for the enrollee's diagnosis.
The requested device is not medically reasonable or necessary to treat 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve extracellular fluid analysis for lymphedema assessments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable bed.
You asked the Plan to pre-approve the requested bed. You say that the enrollee has a large hiatal hernia. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The file shows that an adjustable bed base was requested. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an adjustable bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Disc-FX procedure (62287).

You asked the Plan to pre-approve a Disc-FX procedure. You say that the requested services are a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested
services have not been met.

The Plan must follow Medicare rules. Medicare rules say that PILD for LSS may only be covered under the
context of a clinical trial.

We looked at the file and Medicare rules. The Plan has confirmed that the enrollee is not participating in a
clinical trial. Based on this information, we decided that Medicare rules for coverage of a Disc-FX procedure
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Disc-FX procedure
(62287).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular medicine (CPT 93228) services provided to the enrollee on December 22, 2020.

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 the units exceed days in time span.

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 93228 is "External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional 

We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 93228 was billed and paid to provider for date of service December 2, 2020. Therefore, services reported for dates of service December 18, 2020 would not be covered. Per CMS; CPT 93228 and CPT 93229 can only be reported every 30 days. 

We looked at this coder's review, the file, and Medicare rules. 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 cardiovascular medicine (CPT 93228) services provided to the enrollee on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.

You asked the Plan to pre-approve the complete upper and lower dentures. You say that you cannot eat without dentures. You say that your caregiver threw the previous pair away. The Plan denied your request. The Plan says the request for dentures exceeds your benefit limitation.

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 coverage for dentures is limited to one every 5 plan years. The records show that coverage was previously provided for dentures on March 11, 2019. This means that your benefit for coverage of dentures is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Urine PCR panel (CPT code(s): 87798, 87799, 87482) provided to the enrollee on February 9, 2021.
You asked the Plan to pay for the laboratory testing. You say that this test is beneficial over the traditional testing because the results are back within 24 hours opposed to 3-4 days. You state it can reduce the use of hospitalization and inaccurate medication being subscribed. The Plan denied your request. The Plan says these services are experimental or investigational services that are not covered.
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 pay for the laboratory testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review has determined that the items/services at issue in this case were not medically reasonable and necessary. 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 laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for Urine PCR panel (CPT code(s): 87798, 87799, 87482) provided to the enrollee on February 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable foot insert (L3020).
You asked the Plan to pre-approve a removable foot insert. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve a removable foot insert (L3020).