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

We decided that the Plan does not have to waive the copayment for the CT scan.

You asked the Plan to waive the copayment for the CT scan. You say that you were referred to the specialist by
your doctor. The Plan denied your request. The Plan says advanced imaging services require a $180
copayment.

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 $180
copayment for advanced imaging services.

You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the advanced imaging
services (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 copayment for the CT scan.

Please note, the Plan has indicated that you have already paid the required copayment to the provider. Please
contact the Plan for more information.
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.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee could be treated at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical
record documents a need for physical and occupational therapy but not for an intensive rehabilitation program.
There is a not reasonable expectation that this patient will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator, with
integrated electrocardiogram analysis, garment type (K0606).

You asked the Plan to waive the coinsurance for automatic external defibrillator. You say that the item should
be covered. The Plan denied your request. The Plan says the cost share was applied 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 20%
coinsurance for durable medical equipment (DME) and related supplies.

You have been asked to pay a 20% coinsurance for automatic external defibrillator. This item falls within the
durable medical equipment (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 automatic external defibrillator, with integrated electrocardiogram analysis, garment type
(K0606).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and crown (D2740).

You asked the Plan to pay for the preventive procedure and crown. You say that you do not feel that you were
notified that you would be responsible for a 50% coinsurance for the crown. The Plan denied your request. The
Plan says the preventive procedure is not a covered service. The Plan also says that your responsibility of $315
for the crown is correct.

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, unspecified preventive procedure
(D1999) is not among those covered under this benefit. The Plan contract also clearly states that you must pay
a 50% coinsurance for crowns. Therefore, we decided that the Plan does not have to pay for the preventive
procedure (D1999) and crown (D2740).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for endoscopy services provided to the enrollee.

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 claim was submitted after timely filing limitations.

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 services was not filed until August 20, 2020. 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 endoscopy services provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI).

You asked the Plan to pre-approve MPI test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because follow-up MPI is only supported once per 2 years but the enrollee had a previous MPI study.

The Plan follows Medicare rules. Medicare rules say that MPI testing for excessive frequency is not 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 MPI test. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MPI test. Our physician reviewer found the available records do not justify the need for the requested follow-up myocardial perfusion imaging study as no acute or chronic cardiac signs or symptoms are documented and no other information is provided to warrant a follow-up study at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MPI test have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0425, A0426).

You asked the Plan to pay for ambulance transportation. You say that this was medically necessary. The Plan denied your request. The Plan says this trip was not to a covered destination.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 ambulance transportation. Our reviewer says that the criteria for coverage of ambulance transportation have not been met. Our physician reviewer found the records show that the enrollee was clinically stable. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable and necessary for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0426).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the dental services.

You asked the Plan to reimburse you for the dental services. You say that you pay a premium for dental so the Plan should reimburse you. The Plan denied your request. The Plan says they will not reimburse for charges incurred by Medicare Opt Out providers.

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 reimburse you for the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and endodontic therapy (D3330).

You asked the Plan to pay for the preventive procedure and endodontic therapy. You say that you would like these services to be covered because a Plan representative advised that this provider was in-network. The Plan denied your request. The Plan says the preventive procedure is not covered under your dental plan. The Plan also says that you are responsible for 50% of the cost for the endodontic therapy.

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, preventive procedure (D1999) is not among those covered under this benefit. The Plan contract also clearly states that you are responsible for a 50% coinsurance for endodontic therapy (D3330). Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and endodontic therapy (D3330).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and ophthalmoscopy provided by an OON provider.

You asked the Plan to pay for the eye exam and ophthalmoscopy. You say that the enrollee did not have any
input in choosing who he saw. You also say that a provider performing services in a nursing home facility is
not responsible for obtaining authorization. The Plan denied your request. The Plan says the services were
rendered by an OON provider. The Plan also says that a 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 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 eye exam and ophthalmoscopy provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an OON provider.

You asked the Plan to pay for skilled nursing services. You say that these services are provided in good faith.
You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 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 skilled nursing services provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa 20mg/2ml syringe for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a step therapy exception cannot be granted.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 services. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial
of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not
tried and failed the required drugs. There is no documentation provided indicating that the plan's required
drugs would likely be less effective and/or likely have adverse effects for 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Euflexxa 20mg/2ml syringe for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
codes cannot be verified.

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 G0500 is Moderate sedation services provided by the
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the
patient's level of consciousness and physiological status.

The CPT Code Manual definition of code 99153 is Moderate sedation services provided by the same physician
or other qualified health care professional performing the diagnostic or therapeutic service that the sedation
supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's
level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in
addition to code for primary service).

We find that CPT code G0500 is not supported in the medical record. The records do not indicate that the
sedation services provided required the presence of an independent trained observer. Because the primary code
G0500, is not covered, code 99153 is also not covered. Based on this information, we decided that Medicare
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the
moderate sedation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins
when required (D2950), or pay more for the two resin-based composites (D2391 x2) provided by an OON provider.

You asked the Plan to pay for the crown and core buildup, and pay more for the resin-based composites. You
say that you would like these services to be covered according to the predetermination you received. The Plan denied your request. The Plan says the crown and core buildup are not covered services. The Plan says that the claim for the resin-based composites processed correctly, and you are responsible for the OON coinsurance.

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, crown (D2750) and core buildup,
including any pins when required (D2950) are not among those covered under this benefit. The Plan contract
also clearly states that you must pay a 70% coinsurance for resin-based composites (D2391) that are received
OON.

Though you received a predetermination in December 2019, these services were provided during the 2020 Plan
year, hence the 2020 coverage rules apply. Therefore, we decided that the Plan does not have to pay for the
crown (D2750) and core buildup, including any pins when required (D2950), or pay more for the two resinbased
composites (D2391 x2) provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of SNF care because his needs are custodial and can be met at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and clear lungs. The enrollee received physical therapy in the acute hospital. The enrollee was at a stand-by assist to modified-independent level with functional mobility, including gait to 200 feet with no assistive device. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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.

You asked the Plan to pre-approve IRF care. You say that the enrollee is an excellent candidate for IRF care as she was fully independent prior to her stroke, and she is highly motivated to participate in the therapy program. The Plan denied your request. The Plan says the enrollee has no medical need for the IRF level of care. Her needs can be met in a skilled nursing facility. 

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 patient was admitted for left sided weakness and was treated for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided in a lower level of care. There is a not reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.