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

We decided that the Plan does not have to pay for continuation SNF services from August 29, 2020, through September 26, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee returned to baseline and did not have skilled nursing needs. The enrollee's latest level of function, as documented on the most recent PT and OT evaluations, was walking 60 feet and doing most other activities without hands on assistance.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. She was treated for low back pain. Regarding rehabilitation services, the enrollee received physical therapy in the SNF. By the dates in question, the enrollee was at a modified independent /supervision to contact guard assist level with functional mobility including gait to 60 feet x 3 with a rolling walker. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.

The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, 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 pay for continuation of SNF services from August 29, 2020, through September 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on January 6, 2021.
You asked the Plan to waive the copayment for an MRI. You say that this copayment is way too high. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $325 copayment for outpatient diagnostic tests/diagnostic radiology. You have been asked to pay a $325 copayment for an MRI. The correct copayment has been applied to the services that were provided. An MRI falls within the outpatient diagnostic tests/diagnostic radiology 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 an MRI provided by a participating provider on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist services, the echocardiography, the stress test, and the regadenoson injection provided from November 2, 2020 to December 7, 2020.
You asked the Plan to waive the cost share for the specialist services, the echocardiography, the stress test, and the regadeonoson injection. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit, an echocardiography, a stress test, and a regadeonoson injection on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for specialist services, a $25 copayment for an echocardiography, a $100 copayment for a stress test and a 20% coinsurance for a regadeonoson injection. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on November 2, 2020. You have been asked to pay a $10 copayment for the specialist
visit. The specialist visit falls within the Physician/Practitioner services benefit category. The file shows that you received an echocardiography on November 25, 2020. You have been asked to pay a $25 copayment for the echocardiography. The echocardiography falls within the Outpatient diagnostic tests benefit category. The file shows that you received a stress test and a regadenoson injection on December 7, 2020. You have been asked to pay a $100 copayment for the stress test. The stress test falls within the Outpatient diagnostic tests benefit category. You have been asked to pay a 20% coinsurance for the regadenoson injection. The regadenoson injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the specialist services, the echocardiography, the stress test, and the regadenoson injection provided from November 2, 2020 to December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for acupuncture treatment provided from November 9, 2020, through November 17, 2020.

You asked the Plan to reimburse you for the acupuncture treatment. You say that your PCP referred you to have the acupuncture treatment to treat diabetic neuropathy. The Plan denied your request. The Plan says acupuncture is an excluded service and not covered under any condition by plan.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

The contract with the Plan says that acupuncture services are not covered under any condition. 

We looked at the file, the Medicare rules and the Plan's rules. The file shows that the Plan does not allow coverage for acupuncture under any condition. Therefore, we decided that the Plan does not have to reimburse you for acupuncture treatment provided from November 9, 2020, through November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on November 16, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the anesthesia services were provided to the enrollee while the enrollee was inpatient. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on November 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on December 4, 2020.
You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says
payment is included in the inpatient rate.
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation furnished to inpatients
is covered under Part A.
We looked at the file and Medicare rules. The ambulance services were provided while the enrollee was under
inpatient status. Payment for the ambulance services is included in the payment for the inpatient stay. Based on
this information, we decided that Medicare rules for coverage of the ambulance transportation have not been
met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on
December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950) provided on June 12, 2020.
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
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 core buildup (D2950) provided on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the knee injection provided on December 17, 2020.

You asked the Plan to reduce the copayment for the knee injection. You say that the benefit book shows a $30 copayment for all other services. 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 $415 copayment for each in-network Medicare-covered outpatient hospital surgery services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $415 copayment for the knee injection. 

You have been asked to pay a $407.61 copayment for the knee injection. The knee injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital facility. 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 reduce the copayment for the knee injection provided on December 17, 2020.

Please note, our decision is only regarding the December 17, 2020 date of service. Please contact the Plan directly for any questions regard previous years' billing.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have pre-approve ten (10) additional PT visits.

You asked the Plan pre-approve ten (10) additional PT visits. The Plan denied your request. The Plan says ten (10) additional physical therapy sessions from January 5, 2021 through December 31, 2021 are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 pre-approve the ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee can transition to an independent home program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulpal debridement services (D3221).

You asked the Plan to pre-approve pulpal debridement. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan's supplemental dental benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. Additional dental benefits may be provided under the Medicaid portion of the supplemental benefit. 

The services you are asking the Plan to pre-approve 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 pre-approve pulpal debridement services (D3221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride excluding varnish provided on March 2, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride excluding varnish. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services were rendered OON. The Plan also says that you did not contact the Plan prior to the services being rendered to verify the provider network, your eligibility, or benefits, and you were also aware that this provider is OON.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride excluding varnish provided on March 2, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 25, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was a wellness visit and you do not believe that there should be a copayment. 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 $10 copayment per visit for an in-network primary care physician. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows a diagnosis of mild, intermittent asthma in addition to a general adult medical examination. 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 office visit provided on January 25, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Cinvanti.
You asked the Plan to pre-approve Cinvanti. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Cinvanti. Our reviewer says that the medication is medically necessary. Our physician reviewer found this enrollee is on lutetium Lu-177 dotatate which has a emetic risk of nausea and vomiting over 50%. This constitutes a high emetic risk and the use of aprepitant (Civanti) is indicated. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cinvanti have been met. Therefore, we decided that the Plan has to pre-approve Cinvanti.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen tablets.
You asked the Plan to pre-approve Hydrocodone-Acetaminophen tablets. You say that you would like the Plan
to reconsider their denial. The Plan denied your request. The Plan says Hydrocodone-Acetaminophen tablets
are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-
Acetaminophen tablets.
Benefits for Hydrocodone-Acetaminophen tablets may be available under Medicare Part D. Contact the Plan
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgical services rendered on January 14, 2021.
You asked the Plan to waive the coinsurance for these services. You say that no one informed you of the cost. The Plan denied your request. The Plan says the coinsurance 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 per visit for outpatient surgery.
Review of the file shows that you received outpatient surgical services on January 14, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the outpatient surgery 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 outpatient surgical services rendered on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services (93880, 93922, 93978) provided January 5, 2021.
You asked the Plan to waive the copayment for the radiology services. You say that the copayment for the office visit on the same day should have covered this service. The Plan denied your request. The Plan says the imagining services were a separate service. The correct copayment was applied.
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 $55 copayment for x-rays and ultrasounds. You have been asked to pay a $55 copayment for the radiology services. The radiology services fall within the x-rays and ultrasounds benefit category. This is a distinct service from the specialist visit for which the $50 copayment was applied. 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 radiology services (93880, 93922, 93978) provided January 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient observation services
rendered on December 30, 2020 to December 31, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment 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 $210
copayment for each Medicare-covered outpatient hospital observation stay at a hospital facility.
Review of the file shows that you received outpatient observation services from December 30, 2020 to
December 31, 2020. You have been asked to pay a $210 copayment for these services. These services fall
within the Medicare-covered outpatient hospital observation stay at a hospital facility 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 outpatient observation services rendered on December
30, 2020 to December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0482) provided on August 5, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medicaldocumentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 80307 and G0482 is not supported in the record. Specifically, the claim was billed with a laboratory place of service code but the record indicates the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0482) provided on August 5, 2020.