Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 16, 2020.

You asked the Plan to pay for out of network providers. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns provided on October 7, 2020.
You asked the Plan to pay for the crowns. You say that paying the remainder of this bill is a financial hardship for you. The Plan denied your request. The Plan says benefits for this service had been satisfied and the frequency limitation had been exceeded. The Plan also says that you did not contact the Plan prior to this date of service to verify your 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, crowns are limited to one procedure per calendar year. The record shows that you received two crowns on October 7, 2020, one of which was covered by the Plan, and your crowns benefit had been exhausted. The Plan contract also clearly states that you must pay a 70% coinsurance for a crown. The Plan has already paid their 30% coinsurance, and you are responsible for the remainder. Therefore, we decided that the Plan does not have to pay for the two crowns provided on October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray rendered on February 26,
2020.
You asked the Plan to waive the copayment for these services. You say that you would like the charge
removed. 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 $110
copayment for each covered x-ray in the outpatient department of a network hospital or facility.
Review of the file shows that you received a hip x-ray on February 26, 2020. Per the contract with the Plan,
there is a $110 copayment for each covered x-ray in the outpatient department of a network hospital or facility.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the
Medicare allowed amount for these services was $71.73. Given that the allowed amount was less than the $110
copayment, you have been asked to pay $71.73 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the hip x-ray rendered on
February 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment (D1999) provided on October 15, 2020.
You asked the Plan to pay for the personal protective equipment (PPE). You say that the charge for the PPE should not be passed down to you. You say that all dental services require PPE and are tied to the services that were already paid. You say that you have researched other insurance companies and they state that "the patient will not be charged." You also say that you will not make a payment for this service. The Plan denied your request. The Plan says the unspecified preventive service is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the personal protective equipment (D1999) provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 19, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that the lab work was related to your physical and should have no copayment. 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 $10 copayment for Medicare-covered lab services.
You have been asked to pay $9.29, which is less than the standard $10 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory services provided on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine.
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for upper airway resistance syndrome.
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 the machine. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a past diagnosis of OSA and has been on CPAP for years. She has also lost a substantial amount of weight. She needed a new device and therefore had a sleep study on 7/22/2020. This showed no OSA, with an AHI of 0. There were occasional respiratory arousals, but not enough to be consistent with upper airway resistance syndrome (UARS). A repeat sleep study on 8/23/2020 showed the same findings. Thus, the findings indicate the patient does not have either OSA or UARS. CPAP is therefore considered 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 machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) machine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery provided on June 12, 2019.
You asked the Plan to pay for the surgery (19303). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Evidence of Benefits (EOB) was requested from the primary payer but not received.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the EOB from the primary as to what was paid. As the secondary insurer, the Plan cannot be held responsible for the surgery (19303) until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the surgery provided on June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis (L1951) and shoulder elbow wrist hand orthosis (L3960) provided on October 6, 2020.
You asked the Plan to pay for the orthoses. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the procedure modifiers on the claim lines do not match the diagnosis codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes L1951 and L3960 are not supported in the medical record. Specifically, the CPT codes on the claim have been billed with modifiers that specify laterality, but the diagnosis codes are for unspecified sides. There are more appropriate diagnosis codes for the supplies billed. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis (L1951) and shoulder elbow wrist hand orthosis (L3960) provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on August 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 psychotherapy services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 22, 2020.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 the genetic testing is not supported in the medical record. Specifically, the codes billed represent part of an expanded pharmacogenomic panel. The CYP gene panel is a single unit of service and the single code used to report the CYP gene panel is not covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the service is medically necessary. The Plan denied your request. The Plan says your care needs can be provided in a lower level of care setting, such as with home health services.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and you do not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Specifically, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Your needs can be provided in a lower level of care. This means admission to a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on September 29, 2020.
You asked the Plan to pay for the eyewear. You say that this is for glasses after cataract surgery. The Plan denied your request. The Plan says the plan states they contacted the provider's office concerning any recent services related to cataract surgery and the Plan was advised you were last seen by the provider on July 28, 2020, and it was not related to cataract surgery. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The Plan applied the $100.00 maximum benefit to the claim for the purchase of eyewear on September 29, 2020. The services were not provided due to cataract surgery. Your 2020 Eye Wear Rider states the member is entitled to $100 every two years (24 months) toward the purchase of eyeglasses or contact lenses. The Plan paid the $100 and you are responsible for the remainder. Therefore, we decided that the Plan does not have to pay for the eyewear purchased on September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services you received on September 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
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 on September 16, 2020. 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 the ambulance services you received on September 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the taxi rides to doctor visits provided from March 24, 2020, to October 1, 2020.
You asked the Plan to reimburse you for the taxi rides to doctor visits. You say that you scheduled transportation but were not picked up. The Plan denied your request. The Plan says transportation was not provided by the Plan's transportation vendor.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation and members are required to contact the Plan's transportation vendor at least 48 hours in advance of their appointment to schedule non-emergent transportation services to plan approved locations. Transportation arranged outside of the transportation vendor will not be covered.
We looked at your request, the records in the case file, and the rules. Enrollees are required to schedule non-emergent transportation with the Plan's transportation vendor. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to reimburse you for the taxi rides to doctor visits provided from March 24, 2020, to October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision services.

You asked the Plan to pay for the services provided. You say that you could not afford services from a network
provider. The Plan denied your request. The Plan says the provider is not a participating provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.

We looked at the file and the Plan's rules. You must receive services from a network provided. Based on this
information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the
Plan does not have to pay for the routine vision services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the porcelain crown (D2740) provided on August 1, 2020.
You asked the Plan to reimburse you for the dental service. You say that you were never advised that you needed to make sure that your dentist accepted Medicare or was in network. You say that you received an email from the Plan that indicates that a dentist that does not accept Medicare is eligible for reimbursement to the member. You also say that the crown was a major expense for you. The Plan denied your request. The Plan says there is an allowance of $850 per year for non-Medicare covered preventive and comprehensive dental services. The Plan also says that the allowance has been exhausted.
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 $850 allowance has been exhausted. The record shows that the Plan paid $850 for the root canal that you received on December 4, 2020. Additionally, the Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to reimburse you for the porcelain crown (D2740) provided on August 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325) injections.

You asked the Plan to pre-approve Synvisc (J7325) injections. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the records do not show the enrollee has failed to respond to at least 3 months of conservative therapy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The record does not show the enrollee has tried nonsteroidal anti-inflammatory drugs or physical therapy. Based on this information, we decided that Medicare rules for coverage of Synvisc (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325) injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from August 20, 2020 to August 22, 2020.

You asked the Plan to waive the copay for the inpatient hospital services. You say that this should be covered in full. The Plan denied your request. The Plan says that you are responsible for your copay.

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 $270 copay per day for days 1-6 for each Medicare-covered admission. 

You have been asked to pay a $540 copay for the inpatient hospital services. The inpatient hospital services fall within the days 1-6 for each Medicare-covered admission 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 copay for the inpatient hospital services provided from August 20, 2020 to August 22, 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. You say that you had major brain surgery and need high intensity therapy in order to regain function. You say that a skilled nursing facility will not be able to provide the level of care needed. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can safely receive the care needed in another setting.

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 the enrollee appears to require ongoing assistance with various activities but only requires short-term acute care services based on the recent notes. The enrollee does not require services at the LTACH that are already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. 

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.