Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on May 29, 2020.

You asked the Plan to waive the coinsurance for DME. You say that you were given the device after a surgical procedure and had no say in where it came from. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 20% coinsurance for DME and related supplies. 

You received DME on May 29, 2020. The total allowed amount is $2,995 and 20% of that is $599. 

You have been asked to pay the total coinsurance amount of $599 for DME. DME falls within the DME and related supplies 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 coinsurance for DME provided on May 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by an out-of-network provider on October 28, 2020.

You asked the Plan to pay for the laboratory services. You say that the medical center provided emergency services because it was medically necessary and there was not an in-network facility. You say that the patient should not be penalized, and the medical center is willing to accept a negotiated fee for the services performed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided by an out-of-network provider on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the filter (A7038), tubing (A7037), headgear (A7035), water chamber (A7046), full face mask (A7030) and interface (A7031) provided on December 4, 2020.

You asked the Plan to pay for the CPAP supplies. You say that you would like reconsideration because all of the parts that were billed for this date of service meet the required frequency of replacement. The Plan denied your request. The Plan says that modifier GA indicates that a waiver of liability statement was issued as required by payer policy.

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. Specifically, the Plan has failed to forward any evidence as to why you were not due to receive the billed supplies. The limited records provided indicate that you were within the required frequency for replacement time frame. Additionally, the use of the GA modifier does not preclude the Plan's obligation to cover services when medically necessary. This modifier indicates that you were informed that these supplies would not be covered. There is no evidence in the documentation submitted that you were made aware of this. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor Therefore, we decided that the Plan has to pay for the filter (A7038), tubing (A7037), headgear (A7035), water chamber (A7046), full face mask (A7030) and interface (A7031) provided on December 4, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on December 2,
2020.

You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary or rest home visit provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on
September 16, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain
indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare
covers cardiovascular disease screening tests for certain indications, the documentation does not support that
the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for
the cardiovascular risk assessment testing provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on orthopedic surgery (20680, 20902, 28725) provided by a surgical assistant on July 7, 2020.

You asked the Plan to pay for surgical assistant services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered when provided by a surgical assistant.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on orthopedic surgery (20680, 20902, 28725) provided by a surgical assistant on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental filling provided on January 13, 2021.

You asked the Plan to pay for the dental filling. You say that you feel that this was denied due to an issue with your insurance being cancelled. You state that you were still billed for the premium during this time and either want this paid, or to have your premiums refunded. The Plan denied your request. The Plan says this was denied due to the absence of a diagnosis code on the claim submitted by the provider.

The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to determine whether payment is due. 

When submitting a claim for payment, a diagnosis code is required to determine whether the service is provided for a covered indication. In this case, the claim submitted did not include a diagnosis code. As such, it cannot be paid until a corrected claim is submitted. Therefore, we decided that the Plan does not have to pay for the dental filling provided on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant
(D6010) provided July 2, 2020.

You asked the Plan to pay for the endosteal implant. You say that the implant is required to treat injury due to a
fall and should be covered as a medical service. The Plan denied your request. The Plan says the dental implant
is not eligible for medical coverage and you do not have supplemental dental benefits therefore the service is
not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for surgical placement of implant
body: endosteal implant (D6010) provided July 2, 2020.

Your complaint about the Plan covering initial services to treat dental injury due to a fall but the implant not
being covered as a medical benefit under your Plan is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery provided by an out-of-network provider on October 15, 2020.

You asked the Plan to pay for the cataract surgery. You say that the services were provided were medically necessary and payment should be issued. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the cataract surgery provided by an out-of-network provider on October 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient rehabilitation services provided March 4, 2019 by an out of network provider.

You asked the Plan to pay for the inpatient services. You say that the member was provided treatment prior to the parties entering into a preferred provider agreement. Out of network benefits were authorized. Charges totaled $19,200.00. The plan has paid nothing for the services and treatment. The Plan denied your request. The Plan says the claim was submitted past the timely filing limitation.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the inpatient services was not filed until January 5, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the inpatient rehabilitation services provided March 4, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care services coded 99226
provided on September 15, 2020.

You asked the Plan to pay for the subsequent observation care 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 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.

We find that CPT code 99226 is not supported in the medical record. Specifically, this claim was billed with
place of service 22 (outpatient). The documentation shows that the enrollee was inpatient during this date of
service. This means that the incorrect place of service was billed. Based on this information, we decided that
Medicare rules for coverage of the subsequent observation care services have not been met. Therefore, we
decided that the Plan does not have to pay for the subsequent observation care services coded 99226 provided
on September 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 17, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you thought that the charges were going to be covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $240 copayment for ambulance services. 

You have been asked to pay a $240 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity.

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 urinary tract infection, renal failure and metabolic acidosis. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested and reviewed.

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 surgical management of a perforated sigmoid colon. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lenses, single vision provided on October 14, 2020.

You asked the Plan to pay for the lenses, single vision. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 lenses, single vision provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) provided December 24, 2020.

You asked the Plan to pay for the emergency treatment of dental pain. You say that it was an emergency and should be covered. The Plan denied your request. The Plan says emergency services to treat dental pain are not covered under your dental 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) provided December 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a removal of residual tooth roots (D7250) provided on August 26, 2020.

You asked the Plan to pay for the root extraction. You say that you are in the Plan's network and this claim should be reprocessed. The Plan denied your request. The Plan says that this service is not covered under the supplemental dental benefit. In addition, your network status was not effective until September 2020. At the time of service, you were not part of the Plan's network. Out-of-network dental care 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 items or services requested are not among those covered under this benefit and were provided out-of-network. Therefore, we decided that the Plan does not have to pay for a removal of residual tooth roots (D7250) provided on August 26, 2020.