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

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of inpatient skilled nursing 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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a skilled nursing facility. The patient does not have complex wound care or other skilled nursing needs that require a skilled nursing facility stay. He has no IV medications. He has a stable trach and stable tube feedings. His conditions are chronic and stable. The patient 's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a skilled nursing facility. Additionally, skilled services are not needed on a daily basis or as practical matter 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291).

You asked the Plan to pay for critical care. You say that this was billed correctly. The Plan denied your request. The Plan says this service is not documented in the records.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the submitted medical records do not document the time spent on critical care services on any of the billed dates of service. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the head (70450).

You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not eligible for separate payment.

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, we have confirmed that code 70450 has a Column One/Column Two relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of the head (70450).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medication Euflexxa (J7323).

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of this medication.

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 this medication. Our reviewer says that you do not meet criteria for coverage of this medication. Our physician reviewer found that the Plan requires a trial of Orthovisc and Synvisc medications first before they will approve the requested drug. In this case, you have not tried and failed the required drugs. Additionally, there is no documentation provided indicating that the plan's required drugs would likely be less effective and/or would have adverse effects.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the medication Euflexxa (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share for out of network dental services.

You asked the Plan to review these dental services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says they will only cover the dental services listed in the Evidence of Coverage. The Plan states that dental services D0431, D4381, D4921, and D9630 are not included in the list of covered services. The Plan contract also states that providers are paid based on the Maximum Allowable Charge (MAC) for dental services and that you may still be billed by an out-of-network provider for any amount greater than the payment made by the Plan.

Medicare does not cover dental services. 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, you are only covered for those services listed in the Plan contract and the use of out of network dental providers will require a higher cost share. Therefore, we decided that the Plan does not have to waive or reduce the cost share for out of network dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services.

You asked the Plan to pay for the services provided. You say that the enrollee was in outpatient observation. The Plan denied your request. The Plan says the services were billed with an inappropriate place of service code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

The file shows that office visits (99204 and 99214) were billed for observation services. The claim also shows that a place of service code for an emergency room was billed. We find that the provided services were not billed correctly per Medicare guidelines. The claim was not billed with valid observation codes, nor was it billed with a correct place of service. 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 evaluation and management services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that you do not agree with the Plan's denial. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.

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 medical services provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99309).

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services (99309).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) for tooth #29.

You asked the Plan to pay for the crown. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for crowns was exhausted at the time the service was performed.

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 benefit for crowns was exhausted at the time the service was performed. A crown was already placed on Tooth #29 within the past 5 years. Therefore, we decided that the Plan does not have to pay for a crown (D2740) for tooth #29.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care.

You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the inpatient skilled nursing facility care provided was not medically necessary.

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 pay for the SNF care. Our reviewer says that the inpatient skilled nursing facility care provided was not medically necessary. Our physician reviewer found that the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse was required to safely and effectively provide medically necessary and reasonable treatment in a skilled nursing facility. The patient did not have complex wound care or other skilled nursing needs that required a skilled nursing facility stay.

The patient's functional level did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a skilled nursing facility. Additionally, skilled services were not needed on a daily basis or as practical matter 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0299).

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was missing required information.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code G0299 is not supported in the medical record. Specifically, the claim submitted did not include the required "Q" code to denote the location in which the services were provided. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) provided by an out of network (OON) provider.

You asked the Plan to pay for MRI. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the service could have been performed within the Plan 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 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 Magnetic Resonance Imaging (MRI) provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the endodontic therapy, molar tooth (excluding final restoration) (D3330).

You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.

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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the endodontic therapy, molar tooth (excluding final restoration) (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Intraoral x-rays (D0220, D0230) and periodontal maintenance (D4910).

You asked the Plan to pay for the intraoral x-rays and periodontal maintenance. You say that the services were medically necessary. The Plan denied your request. The Plan says these services were not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for Intraoral x-rays (D0220, D0230) and periodontal maintenance (D4910).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive thee copayment for an urgent care visit (99204).

You asked the Plan to waive thee copayment for the urgent care visit. You say that the copayment should only be $35. The Plan denied your request. The Plan says 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 $65 copayment for urgent care visit.

You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the 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 thee copayment for an urgent care visit (99204)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (20610).

You asked the Plan to waive the copayment for the injection. You say that the surgery copayment was incorrectly applied, you only had an injection. The Plan denied your request. The Plan says the injection is considered a surgical service and 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 $200 copayment for outpatient surgery.

You have been asked to pay a $200 copayment for the injection. The injection falls 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 copayment for an injection (20610).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for two Urologist visits (99214, 51798, 99204, 81015).

You asked the Plan to waive the copayments for the urologist visits. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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 $35 copayment for specialist visits.

You have been asked to pay two $35 copayments (a total of $70) for the urologist visits. The urologist visits fall within the specialist 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 copayments for two Urologist visits (99214, 51798, 99204, 81015).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service with no transportation.

You asked the Plan to pay for ambulance service. You say that you did not request this ambulance and refused service from them. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance service with no transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (87804, 99000).

You asked the Plan to waive the copayment for the lab services. You say that the copayment should be waived. The Plan denied your request. The Plan says the services at issue were not related to COVID-19 and the correct cost-sharing 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 $20 copayment for laboratory tests.

You have been asked to pay a $20 copayment for the lab services. The lab services fall within the laboratory tests 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 lab services (87804, 99000).