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

We decided that the Plan does not have to pay for office services provided on September 12, 2020 to December 5, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office services. You say that if these services had not been provided, the enrollee would not have made it to her medical appointments which would have caused her health to be compromised. 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 does not participate in Medicare.

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 office services provided on September 12, 2020 to December 5, 2020 by an out of network (OON) provider.
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 LTACH care is not medically necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pay for the bilateral salpingo-oophorectomy with omentectomy. We decided
that the Plan does not have to pay for umbilical hernia repair (49585), bladder wound repair (51860) and
suspension of the vagina (57280).
You asked the Plan to pay for the umbilical hernia repair (49585), bladder wound repair (51860), suspension of
the vagina (57280) and bilateral salpingo-oophorectomy with omentectomy (58954) provided on June 26,
2020. You say that you would like reconsideration based on the records submitted. The Plan says that these
services have been billed with invalid or missing modifiers.
We decided that the Plan has to pay for bilateral salpingo-oophorectomy with omentectomy (58954).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
Per the Physician Fee Schedule, CPT code 58954 has a bilateral indicator of 2. This means that CPT code
58954 is eligible for the bilateral adjustment payment and modifier 50 has been reported appropriately.
Therefore, we decided that the Plan has to pay for bilateral salpingo-oophorectomy with omentectomy (58954).
We also decided that the Plan does not have to pay for umbilical hernia repair (49585), bladder wound
repair (51860) and suspension of the vagina (57280).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
Per the Physician Fee Schedule, CPT codes 49585, 51860 and 57280 have a bilateral indicator of 0. This means
that these codes are not eligible for the bilateral adjustment payment. Modifier 50 is not appropriate to report
with these codes. Therefore, we decided that the Plan does not have to pay for umbilical hernia repair (49585),
bladder wound repair (51860) and suspension of the vagina (57280).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex 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 there is a lack of evidence to support this device as a safe and effective treatment for lumbar spinal stenosis.

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 of the device.

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 Coflex device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from May 27, 2020 to October 7, 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 the claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required TOB code 032x. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from May 27, 2020 to October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the breast.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the medical necessity for advanced imaging has not been established.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no documented increased risk of malignancy such as BRCA-1 mutation. In addition, no conventional imaging (such as mammography or ultrasound) has been done, which is required in order to qualify for an MRI exam as a problem-solving tool. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the breast.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 25, 2021 by an out of network (OON) provider.

You asked the Plan to pay for drug testing. You say that you performed this testing in good faith at the request of the ordering physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network 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 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 drug testing provided on February 25, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 90 additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you do not drive, and you have 4 upcoming appointments that you need transportation to. The Plan denied your request. The Plan says you have exceeded your benefit allowance and the additional routine transportation trips are not covered by your health plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way routine transportation trips per year.
We looked at your request, the records in the case file, and the rules. The records show that, at the time you filed your appeal, 56 one-way routine transportation trips had been covered in the 2021 calendar year. Based on this information, we decided that the number of additional trips being requested would exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 90 additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on June 2, 2020 by an OON provider.
You asked the Plan to pay for the initial nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
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 initial nursing facility care provided on June 2, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiation treatment provided December 7, 2020, to December 31, 2020.

You asked the Plan to waive the copayments for the radiation therapy. You say that insurance should pay for the expenses because they are very high for your income. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $40 copayment for Medicare-covered therapeutic radiology services.

You have been asked to pay a $40 copayment for the radiation therapy on each date of service. ($40 x 15 dates of service = $600). The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayments for the radiation treatment provided from December 7, 2020, to December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the microfluidic analysis provided on October 23, 2020.

You asked the Plan to pay for the services provided. You say that the claim was processed correctly with two
units and no modifier. The Plan denied your request. The Plan says the code was billed without a required QW
modifier.

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 83861 is microfluidic analysis utilizing an integrated
collection and analysis device, tear osmolarity. We looked at the file and the rules. The claim provided does not
show the code at issue was billed with an appropriate modifier. Based on this information, we decided that
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the microfluidic analysis provided on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 27, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 28, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel testing provided on
November 3, 2020.

You asked the Plan to pay for the testing services. You say that the results of the testing allow physicians to
make treatment decisions for enrollees. The Plan denied your request. The Plan says Medicare denies coverage
for all cardiovascular risk assessment panels, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed
above, are not covered.

The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing
for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive
cardiovascular panel testing provided on November 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
September 1, 2020, to September 22, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you do not believe you should be liable.
The Plan denied your request. The Plan says the claim has processed correctly.
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 $0
copayment per days for days 1-20 and a $178 copayment per day for days 21-100 for SNF care.
You have been asked to pay a total copayment of $178 for 21 days of SNF care. This service falls within the SNF care 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 skilled nursing facility (SNF) care provided September 1, 2020, to September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve for inpatient hospital care.

You asked the Plan to pre-approve for the inpatient hospital care. You say that you are in a lot of pain, and it is
affecting everything you do. You say that you have sharp pains and aches constantly and that you are
miserable. The Plan denied your request. The Plan says the approved elective shoulder arthroplasty is not on
the inpatient only list and can be provided as an ambulatory procedure. The Plan says that there is no
documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 for the inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient hospital admission are met
in this case. Our physician reviewer found the enrollee is medically stable. The right shoulder arthroplasty has
been approved by the Plan, but this procedure is not on the Medicare inpatient only list. There is no specific
clinical rationale for the requested inpatient admission. The records do not show that the physician reasonably
expects that the enrollee's necessary hospital care would span two midnights.

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 inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve for inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) for tooth 5 (D3320) provided December 5, 2020 and the post and core in addition to crown, indirectly fabricated for tooth 4 and 5 (D2952) or provide additional payment for the crown - porcelain/ceramic for tooth 5 (D2740) provided December 9, 2020.
You asked the Plan to pay for the second root canal, post and core, and second crown. You say that you believed this provider to be in-network based on information provided by the Plan and therefore the Plan should cover the services. The Plan denied your request. The Plan says a one-time exception has been made to reprocess the claims as in-network, however, the post and core is not listed as a covered service and the second root canal is not covered because you have exceeded frequency limits and the second crown is only partially covered because you reached your annual maximum for 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. The Plan covers several dental services including one root canal and two crowns per calendar year up to a $3,000 annual maximum. The Plan does not cover posts and cores. We looked at the file and Medicare rules. In this case the Plan has already covered one root canal on the same date of service. The Plan has covered the second crown up to the enrollee's annual maximum. The enrollee is responsible for the remaining cost above the annual maximum. Although the Plan provides coverage for dental services, the post and core is not among those services listed in the dental benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) for tooth 5 (D3320) provided December 5, 2020 and the post and core in addition to crown, indirectly fabricated for tooth 4 and 5 (D2952) or provide additional payment for the crown - porcelain/ceramic for tooth 5 (D2740) provided December 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 13, 2021.
You asked the Plan to pay for the dental service. You say that the enrollee was unable to get ahold of their regular dentist. You say that the enrollee had to end up finding a new dentist. You say that you do not feel that it is your fault that you had to find a new dentist. You also say that you feel that this service should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The Plan also says that the frequency limit has been exceeded.
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 and comprehensive oral evaluation is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on April 12, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen (14) home health aide services.

You asked the Plan to pre-approve the home health aide services. You say that you need home health aide to help with bathing, changing linens, applying lotion, and other services of involving activities of daily living (ADL). The Plan denied your request. The Plan says Medicare does not cover custodial care services.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve fourteen (14) home health aide services.