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

We decided that the Plan does not have to waive the copayment for an outpatient non-surgical visit and coinsurance for an injection provided by a participating provider on August 13, 2020.
You asked the Plan to waive the copayment for an outpatient non-surgical visit and coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct charges have 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 $150 copayment for outpatient surgery/non-surgical visit and a 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a $150 copayment for an outpatient non-surgical visit and less than a 20% coinsurance of the allowed amount for an injection due to reaching your maximum out-of-pocket expense. The total amount you are being asked to pay is $406.98. An outpatient non-surgical visit falls within the outpatient surgery/non-surgical visit benefit category and an injection 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 copayment for an outpatient non-surgical visit and coinsurance for an injection provided by a participating provider on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel testing provided on September 4, 2020.

You asked the Plan to pay for the testing services. You say that the testing will guide appropriate medical management of the enrollee. The Plan denied your request. The Plan says the services are not medically necessary.

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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. 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 Tempus gene panel testing provided on September 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 30, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER but were never seen by a doctor. You say that the bill was over $2,000 when no medical help was given. The Plan denied your request. The Plan says the copayment 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 $120 copayment per Medicare-covered emergency room visit.
You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you received services during the 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 ER visit provided on December 30, 2020.
Your complaint about the visit being traumatizing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device for the enrollee.

You asked the Plan to pre-approve these services. You say that this medically necessary for the enrollee. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation provided on January 5, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this is not a covered service under your plan.

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 cone beam CT capture and interpretation provided on January 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-
hour facility (99053) and chest x-ray (71045) provided on December 6, 2020.

You asked the Plan to pay for the chest x-ray and additional services.. You say that you would like
reconsideration because this claim was billed with the appropriate place of service. The Plan denied your
request. The Plan says this claim was billed with an outpatient place of service code but the member was
registered inpatient on the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT codes 99053 and 71045 are not supported in the record. Specifically, this claim was billed with an outpatient place of service code, but the record indicates that the member was registered inpatient on the billed date of service. Additionally, CPT code 99053 has a status indicator of B which means that the payment for this code is always bundled into the payment for another service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray and additional services. have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility (99053) and chest x-ray (71045) provided on December 6, 2020.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.
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 physician reviewer found that the enrollee was admitted to the acute hospital for severe mitral valve regurgitation. Her hospital course has been complicated by fungemia, severe alcohol withdrawal, aspiration pneumonia, septic shock, urinary tract infection, and anemia. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and injections provided by an out-of-network provider on December 10, 2020.

You asked the Plan to pay for the office visit and injections. You say that the visit and procedure were medically necessary. You say that without treatment the patient could experience permanent skin scarring. The Plan denied your request. The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 injections provided by an out-of-network provider on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Liquid CDx testing provided on November 17, 2020.
You asked the Plan to pay for the testing services. You say that the test results were needed to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says the technical assessment has not been completed.
The Plan must follow Medicare rules. Medicare rules say that diagnostic lab tests are only covered under certain medical indications.
We looked at the file, and Medicare rules. In this case, there are insufficient medical records from the ordering physician to show the results of the testing will be used for a specific treatment strategy. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Liquid CDx testing provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for dialysis provided from December 3, 2020, through January 30, 2021.

You asked the Plan to waive the cost for dialysis. You say that there was no copayment or fee until you transferred to this dialysis center. You say that there must be something wrong with the change in what you must pay. The Plan denied your request. The Plan says the cost share 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 2020 contract with the Plan clearly says that you must pay a $30 copayment per treatment. Your 2021 contract with the Plan clearly says that you must pay 20% coinsurance per Medicare-covered dialysis treatment.

You have been asked to pay a total of $1,341.60 for the dialysis treatments.

Dates of Service
Service
Allowed Amount
Standard Cost
Member Liability

December 3, 2020- December 31, 2020
Dialysis
$4,758
$30 per treatment
$390

January 3, 2021- January 30, 2021
Dialysis
$4,758
20% per treatment
$951.60

TOTAL:
$1,341.60

Dialysis falls within the "Services to treat kidney disease" 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 cost for dialysis provided from December 3, 2020, through January 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Movantik.

You asked the Plan to pre-approve Movantik. You say that the enrollee has tried and failed over the counter medications. The Plan denied your request. The Plan says Movantik is not covered under the Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Movantik.

Benefits for Movantik 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on October 20, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 psychotherapy services (90832) provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and oral evaluation (D0120) provided on September 30, 2020.
You asked the Plan to pay for the x-rays and evaluation. You say that you know you have additional money in your annual dental allowance and feel you should have more reimbursement for the services provided. The Plan denied your request. The Plan says You previously had bitewing x-rays provided and paid for by the Plan in February 2020. One set of bitewing x-rays may be covered per year, so the benefit has been exhausted for this service and you are responsible for the full amount. The oral evaluation is covered; however, you used an out-of-network provider and are responsible for the difference between what the provider billed for the service and the Plan's maximum allowable fee for the service. Your benefits were applied correctly.
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. The Plan can cover one set of bitewing x-rays per calendar year. Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency not covered under this benefit. Documentation shows that the Plan paid for bitewing x-rays for you in February 2020. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 30, 2020.
The rules also 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 if you use an out-of-network provider, you may be billed for any amount greater than the payment made by the Plan to the provider.
You have been asked to pay $43 for the evaluation provided on September 30, 2020. You used an out-of-network provider, which means that this provider has not agreed to the negotiated rate for services set by the Plan. The Plan's maximum allowable fee for this evaluation is $21. The provider billed the Plan $64. The Plan paid the full $21 allowed, but you are responsible for the difference between the provider's fee and the Plan's maximum allowed amount. ($64 - $21 = $43). 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 pay any additional amount for the oral evaluation (D0120) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival flap procedure, including root planing, 1 to 3
contiguous teeth or tooth bounded spaces per quadrant (D4241) provided on January 13, 2021.

You asked the Plan to pay for the dental service. You say that you feel that this service was denied in error.
You say that this service resulted in needing an extraction. You say that you do not understand why the cost of
several teeth per quadrant (D4240) would be covered, but this procedure (D4241) would not be covered. The
Plan denied your request. The Plan says the gingival flap procedure, including root planing, is not listed as a
covered service. The Plan also says that D4240 is not listed as a covered service either.

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
gingival flap procedure, including root planing, 1 to 3 contiguous teeth or tooth bounded spaces per quadrant
(D4241) provided on January 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ED visit provided on November 9, 2020.
You asked the Plan to pay for the ED visit. You say that you believe this service should be covered. The Plan denied your request. The Plan says you were under the Certified Hospice program on this date of service. The Plan also says that this claim will need to be submitted to Original Medicare for consideration of payment.
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 the ED visit provided on November 9, 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 for the enrollee.
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of lower leg fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two bone grafts in conjunction with periradicular surgeries (D3428 x2) provided on May 14, 2020.
You asked the Plan to pay for the bone grafts. You say that you feel that these services should be covered. The Plan denied your request. The Plan says these services are not covered.
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 two bone grafts in conjunction with periradicular surgeries (D3428 x2) provided on May 14, 2020.