Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 9, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

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 October 28, 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 the services provided on June 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sinus endoscopy (31256, 31267) provided March 11, 2019.

You asked the Plan to pay for the sinus endoscopy. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 31256, & 31267 are not supported in the medical record. Specifically, the operative report does not support the services billed. Based on this information, we decided that Medicare rules for coverage of the sinus endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a sinus endoscopy (31256, 31267) provided March 11, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from October 16, 2020 to October 23, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan denied your request. The Plan says that the acute hospital stay was not medically necessary.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for inpatient hospital services provided to the enrollee from October 16, 2020 to October 23, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided by an out of network (OON) provider.

You asked the Plan to pay for the transportation services. You say that the documentation details the enrollee's medical necessity. The Plan denied your request. The Plan says non-emergent services rendered by non-participating 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 had network providers available to provide the transportation services at issue in this appeal. 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 the ambulance transportation services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and lesion removal provided by an out-of-network provider.

You asked the Plan to pay for the office visit and lesion removal. You say that the enrollee did not inform you he was under an HMO plan. The Plan denied your request. The Plan says prior approval is required for out-of-network services.

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 office visit and lesion removal provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye exam and eyewear provided by an out-of-network provider on August 29, 2020.

You asked the Plan to pay for routine vision care. You say that you were not aware that this provider was no longer participating with the Plan. The Plan denied your request. The Plan says the denial of payment for these charges is correct, because routine vision care is not covered when obtained from an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from the Plan's routine vision care network. 

We looked at the file and the Plan's rules. Routine vision benefits are not covered when obtained from an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of routine vision care have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye exam and eyewear provided by an out-of-network provider on August 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and heel stabilizer (L3170).

You asked the Plan to pay for the ankle foot orthosis and heel stabilizer. You say that the requested items were medically necessary for the enrollee. The Plan denied your request. The Plan says there was no established relationship between the prescribing physician and the member.

The Plan follows Medicare rules. Medicare rules say that the ankle foot orthosis and heel stabilizer are subject to the criteria listed 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 pay for the ankle foot orthosis and heel stabilizer. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found a physical examination of the ankle and foot would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthosis and heel stabilizer were medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the ankle and foot.

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 ankle foot orthosis and heel stabilizer have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1971) and heel stabilizer (L3170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your records show that it is not likely that you require hospital-level care for 25 days or more.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear to be improving and require only short-term additional acute care services for basic wound care that can be safely received in the current facility. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (CPT Code(s) D1206, D2331, D2740, D2950, D4341, D4921, D5225, D5226, D9911, and D9999.

You asked the Plan to pre-approve the dental services. You say that you cannot chew your food. The Plan denied your request. The Plan says the services are not approved.

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. The services requested for D1206, D2740, D2950, D1206, D2740, D2950, D4341, D4342, D4921, D5225, D5226, D9911, and D9999 are not covered benefits under your Dental plan. Furthermore, the service requested for D2331 exceeds your plan limitation. The Dental network provider, records indicate you were approved for this service with a participating provider. According to your 2021 dental plan, your benefit provides coverage for 2 fillings per year per year. Therefore, your benefit limit has been exhausted for the 2021 plan year. Therefore, we decided that the Plan does not have to pre-approve (CPT Code(s) D1206, D2331, D2740, D2950, D4341, D4921, D5225, D5226, D9911, and D9999.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the lumbar spine.

You asked the Plan to waive the copayment for the CT scan. You say that it is unfair that the plan paid such a small portion towards this CT scan. You stated that you believe the copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment 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 $150 copayment for diagnostic radiology services other than ultrasounds. 

You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the diagnostic radiology services other than ultrasounds 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 computed tomography (CT) scan of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #'s 20, 21, 27, and 28 and removal of residual tooth roots (D7250) of tooth #'s 6, 7, 8, 9, 11, 12, 14, and 16.

You asked the Plan to pre-approve the requested dental services. You say that these dental services are necessary. The Plan denied your request. The Plan says a portion of the extractions requested would be approved if requested under the appropriate code.

The Plan must follow Medicare rules. Medicare only pays for dental services that are medically necessary beyond the supplemental benefit. We asked our physician reviewer look at the dental records and the Plan contract agreement. Our physician reviewer says the request is for surgical extractions (D7210) of tooth #'s 20, 21, 27, and 28 and removal of residual tooth roots (D7250) of tooth #'s 6, 7, 8, 9, 11, 12, 14, and 16. Teeth #20,21,27 and 28 can be seen on the supplied radiographs as having structure present above the gum-line, and significant bone loss due to severe periodontal disease. It is likely these teeth are mobile in the gums due to the advanced periodontal disease. There is no indication that bone would need to be cut to remove these teeth, a requirement of code D7210 and there would not be medical necessity found for removal of these teeth under the supplied surgical code. Teeth #6, 8,9,10 appear to be sufficiently submerged in the bone that there may be need for a cutting procedure to remove them. They would be considered residual roots given the ADA Guide to Extractions - Tooth and Remnants. Teeth #11,12 and 13 have some coronal structure or exposed tooth structure and may be considered under a different extraction code. #7 and #14 have remaining roots not encased in bone and only sitting in soft tissue and would not qualify for a surgical extraction code. Therefore, coverage is not found to be necessary based on the codes submitted.

We looked at the Plans contract rules and the medical review. Based on this information, we find the dental services requested cannot be approved based on the codes provided. Both the Plan and the medical review have stated some of these services may be provided if the appropriate code were submitted. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #'s 20, 21, 27, and 28 and removal of residual tooth roots (D7250) of tooth #'s 6, 7, 8, 9, 11, 12, 14, and 16.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services.

You asked the Plan to waive the copayment for ophthalmology services. You say that you received a diabetic eye exam and should not owe a copayment. 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 $35 copayment for each specialist visit.

You have been asked to pay a $35 copayment for ophthalmology services. Ophthalmology services fall within the physician/practitioner services, including doctor's office visits 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 ophthalmology services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for resin-based filling, three surfaces, posterior (D2393).

You asked the Plan to waive the copayment for the dental services. You say that the annual notice of changes says $0 for fillings. The Plan denied your request. The Plan says a composite resin restoration on a posterior tooth is not a benefit of 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 for posterior composite restorations, the plan will pay only the amount it would have paid to restore the tooth with amalgam.

You have been asked to pay $70 for the dental services. Page 13 of the Dental Summary under Optional treatment says for posterior composite restorations, the plan will pay only the amount it would have paid to restore the tooth with amalgam. You are responsible for the difference in cost. The services fall within the Dental 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 resin-based filling, three surfaces, posterior (D2393).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wound therapy pump (E2402).

You asked the Plan to waive the coinsurance for the wound therapy pump. You say that you were not aware there was a cost with this device. The Plan denied your request. The Plan says the coinsurance processed correctly in this case.

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.

You have been asked to pay a total cost share of $177 ($885 Medicare allowed amount x 20% coinsurance). This service falls within the durable medical equipment 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 the wound therapy pump (E2402).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided by an out-of-network provider.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are available in-network.

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 services at issue in this appeal. 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 the lab services provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220).

You asked the Plan to pay for the dental service. You say that you had x-rays, cleaning and oral exam which are covered services. You also say that the doctor should be paid as soon as possible. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered 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.

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. The Evidence of Coverage clearly states that any services not listed are not covered. Additionally, the record shows that the provider is not billing you for the unspecified preventive service. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug.

You asked the Plan to waive the coinsurance for the Medicare Part B drug. You say that you would like the Plan to waive the coinsurance. The Plan denied your request. The Plan says you were charged the coinsurance 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 20% coinsurance for Medicare Part B Prescription Drugs.

You have been asked to pay 20% coinsurance for the Medicare Part B drug. The Medicare Part B drug falls within the Medicare Part B Prescription Drugs 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 the Medicare Part B drug.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).

You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).