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

We decided that the Plan does not have to waive the copayment for the specialist visit you had on July 15, 2020.
You asked the Plan to waive the copayment for the specialist visit. You say that last year you didn't have to pay anything for this service. You say that this visit was for a mammogram, so there shouldn't be a copayment. 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 $45 copayment for specialist visits. You have been asked to pay a $45 copayment for the specialist visit. We looked at the medical records in this case. In addition to the mammogram you received on this date, you also had an annual surveillance visit at the specialist's office. During this visit, the provider performed a physical exam and full assessment for breast cancer, bone density, and lymphedema. Since you received services beyond a screening mammogram, you are responsible for a copayment for the specialist office visit. 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 specialist visit you had on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on July 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services provided to the enrollee by an out-of-network provider on July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified diagnostic procedure (D0999), unspecified preventative procedure (D1999), and periodontal maintenance (D4910) provided on November 4, 2020.
You asked the Plan to pay for the dental services. You say that these should be covered because you have dental insurance. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental 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 unspecified diagnostic procedure (D0999), unspecified preventative procedure (D1999), and periodontal maintenance (D4910) provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewings, two prophylaxes, and extraction provided from February 26, 2020, to June 25, 2020 by an OON provider.
You asked the Plan to pay more for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewings, prophylaxes, and extraction. You say that you believe these services should be covered. The Plan denied your request. The Plan says the total $309.00 amount applied correctly as enrollee liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation, first intraoral periapical x-ray, bitewings, two prophylaxes, and extraction provided from February 26, 2020, to June 25, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services and radiologic examination of chest provided to the enrollee on August 31, 2020, by non-participating provider.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. According to Medicare guidelines, only the professional component that represents the physician's interpretation of diagnostic tests is considered a physician service and is separately billable to the plan. However, the technical component which represents the test itself, transportation, and set up costs are subject to Consolidated Billing and not separately billable. Under Consolidated Billing guidelines the skilled nursing facility (SNF) must bill the plan for the charges of technical components of diagnostic services. The payment for the technical component is already included within the SNF's payment for the covered stay. Any outside entity that actually furnishes the technical component would
have to look to the SNF for payment. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services and radiologic examination of chest provided to the enrollee on August 31, 2020, by non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN) therapy.
You asked the Plan to pre-approve IDPN therapy. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Parenteral Nutrition Therapy Daily parenteral nutrition is considered reasonable and necessary under specific criteria is met. 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 IDPN therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation to support the enrollee has severe pathology of the alimentary tract which does not allow absorption. The review has determined that the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve a manual wheelchair. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is covered when specific criteria is met. 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 a manual wheelchair. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not support that the enrollee has a mobility deficit that impairs mobility related activity of daily living (MRADLs) in the home and a mobility deficit that is not ameliorated by a walker or cane. The documentation does not support that the enrollee can safely maneuver the wheelchair in the home or that the requested device will significantly improve MRADL participation in the home. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the SNF stay provided from May 15, 2020, to May 30, 2020.
You asked the Plan to reduce the cost share for the SNF stay. You say that you were never told the facility was out-of-network and that you would receive a bill for $5,933.85. You say you would have insisted on an in-network facility if it existed. 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. Your contract with the Plan says that there is a $1,500 deductible that applies towards out-of-network SNF stays and 50% coinsurance per day, days 1 to 100 for an out-of-network skilled nursing facility. The SNF stay you asked the Plan to reduce the cost share for falls within the "Skilled nursing facility (SNF) care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible that applies towards out-of-network SNF stay and 50% coinsurance per day, days 1 to 100 for an out-of-network skilled nursing facility. The record shows the facility is out-of-network. See chart below.
Dates of Service
Service
Allowed Amount
Deductible/Coinsurance
Member Liability
May 15, 2020 to May 30, 2020
SNF stay
$3,168.96
$1,500
$711.42 - You have met your deductible with this amount.
$2,457.54 - This is the remaining allowed amount after the deductible was met
50%
$1,228.77
May 15, 2020 to May 30, 2020
SNF stay
$7,987.33
50%
$3,993.66
Total
$5,933.85
This cost sharing is a contractual obligation that had not been met at the time the SNF stay was received on May 15, 2020 to May 30, 2020. Therefore, we decided that the Plan does not have to reduce the cost share for the SNF stay provided from May 15, 2020, to May 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transportation (R0070) provided on March 11, 2020.
You asked the Plan to pay for x-ray transportation. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, the technical component representing the procedure itself, including any associated transportation and setup costs, is subject to consolidated billing and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part B. We looked at the file and Medicare rules. The record shows that the enrollee was a SNF resident at the time of service, meaning technical components of services, including transportation, cannot be separately billed from the SNF stay. Based on this information, we decided that Medicare rules for coverage of x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation (R0070) provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided September
30, 2020.
You asked the Plan to pay for the orthosis. You say that this enrollee requested services utilizing access to
telemedicine from the physician of their choice in an effort to address COVID-19 concerns. The Plan denied
your request. The Plan says the services are not documented in the medical records.
The Plan must follow Medicare rules. The rules say that the treating practitioner must document and
communicate to the DMEPOS supplier that the treating practitioner has had a face-to-face encounter with the
beneficiary within the 6 months preceding the date of the written order/prescription.
Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee
did not meet the criteria needed for the orthosis provided. The ordering physician specializes in hip and knee
total joint replacement and the claim was for a back brace. The ordering physician would not have seen or
prescribed the enrollee for this type of DME service and has not treated or seen the enrollee to support the
codes billed. Based on this information, we decided that Medicare rules for coverage of the orthosis have not
been met. Therefore, we decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457)
provided September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and biopsies (11102, 11103) provided on October 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON office visit and biopsies. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 an office visit (99213) and biopsies (11102, 11103) provided on October 27, 2020 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 services provided to the enrollee by an out-of-network provider on July 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services provided to the enrollee by an out-of-network provider on July 20, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided 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 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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: 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 you would like reconsideration because LTACH admission is medically necessary. The Plan denied your request. The Plan says you can stay in the hospital to finish your treatments.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that you require that are not already available and covered at the current location. 

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: 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 SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent
basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) provided on September 14, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the record does not support the billed items in this case.
The Plan follows Medicare rules. Medicare rules say that a knee immobilizer without joints, or a knee orthosis with adjustable knee joints , or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control, are covered if the beneficiary has had recent injury to or a surgical procedure on the knee. Additionally, knee orthoses are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the LCD-related Policy Article. 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 these items. Our reviewer says that the record does not support the medical necessity of the billed items in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the left and right knee. The documentation in the case file does not support that the knee orthosis and suspension sleeve provided were medically reasonable and necessary, according to the coverage criteria established by the LCD for the enrollee in this case. There is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Additionally, the suspension sleeve is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on October 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you traveled to the Boston area and within 3 days was admitted to the hospital. You were instructed by the doctor not to leave the Boston area because of your severe situation and the need for several follow up appointments. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99215) provided on October 29, 2020 by an out of network (OON) provider.