Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, problem focused (D0140) received May 5, 2020.

You asked the Plan to pay for the limited oral evaluation. You say that the requested service was necessary. The Plan denied your request. The Plan says you are limited to two oral evaluations per plan year.

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 service is in excess of those covered under this benefit. The Plan has submitted evidence that you received oral evaluations on January 23, and April 27, 2020, exhausting this benefit for the 2020 plan year. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, problem focused (D0140) received May 5, 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 need LTACH level care for her best opportunity for recovery. The Plan denied your request. The Plan says that you do not have a condition complex enough to need continued inpatient hospital care.

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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure, and to pay more for the periodic oral evaluation, prophylaxis, bitewings, and sales tax provided on December 10, 2020 by an OON provider.

You asked the Plan to pay for the preventive procedure, or pay more for the periodic oral evaluation, prophylaxis, bitewings, and sales tax. You say that you believe these services should be covered. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that these services were performed by a non-participating provider, and the enrollee is responsible for any difference between the Maximum Allowable Fee and the amount the provider bills for the services.

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, unspecified preventive procedure is not among those covered under this benefit. The contract also says that the enrollee is responsible for a 50% coinsurance for the periodic oral evaluation, prophylaxis, and bitewings when the service is received out-of-network. The enrollee is also responsible for the difference between the billed amounts and allowed amounts. Therefore, we decided that the Plan does not have to pay for the preventive procedure, and to pay more for the periodic oral evaluation, prophylaxis, bitewings, and sales tax provided on December 10, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on December 8, 2020.

You asked the Plan to pay for the vision services. You say that you did everything listed in the Plan's benefits booklet. You say that your old eyeglasses were damaged, and you needed new eyeglasses. The Plan denied your request. The Plan says the member must receive care from a network provider. The plan will not cover care from a provider who does not work with the health plan unless one of the following situations applies: emergency or urgently needed care from an out-of-network provider, kidney dialysis services that the member gets at a Medicare-certified dialysis facility when they are temporarily outside the plan's service area, and if the member needs medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, the member can get this care from an out-of-network provider, in this case prior authorization is required.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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.

We looked at the file and the Plan's rules. The eyeglasses were not provided by an in-network provider. The Plan had network providers available who could have provided the eyeglasses. The Plan did not pre-approve the eyeglasses. We found no exception that would require the Plan pay for the eyeglasses. Therefore, we decided that the Plan does not have to pay for vision services provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 14, 2021, to January 18, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be responsible for the charges because you were admitted inpatient due to COVID-19 complications. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $385 copayment for days 1-5 for inpatient hospital care.

The medical records show that you had an inpatient hospital stay from January 14, 2021, to January 18, 2021. Therefore, you are responsible to pay a $385 copayment for days 1-4 (January 14, 2021, to January 17, 2021). $385 (copayment) x 4 (inpatient days) = $1,540.

You have been asked to pay the total copayment amount of $1,540 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided from January 14, 2021, to January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 7, 2020.

You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and COVID test provided on October 16,
2020.

You asked the Plan to pay for the office visit and COVID test. You say that you were assured the test was
covered and you would not have to pay. You say that you were incorrectly informed, and the claim should be
paid. The Plan denied your request. The Plan says payment cannot be issued to a provider that has opted out of
Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office
visit and COVID test provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and management of a new patient (CPT code 99204-25) and debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (CPT Code 11042) provided to the enrollee on January 14, 2021.

You asked the Plan to pay for the services. You say that the services meet coding guidelines and were medically necessary. 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. Payment is not allowed for this claim because the place of service billed does not match other claims for the same date of service. This claim cannot be reprocessed for payment until a corrected claim is received. Therefore, we decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and management of a new patient (CPT code 99204-25) and debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (CPT Code 11042) provided to the enrollee on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on December 31, 2020.

You asked the Plan to pay for the panoramic x-ray. You say that your dentist said you needed this x-ray, and you cannot afford this bill. The Plan denied your request. The Plan says you had a complete series of intraoral x-rays on December 1, 2020. The Plan can only cover one x-ray service per year. Therefore, your benefit was already exhausted when you had the panoramic x-ray.

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 x-ray is requested in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on December 31, 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 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. 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 lower extremity pain and weakness and bronchiectesis. The enrollee's medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 cone beam CT capture with interpretation for less than one whole jaw (D0364) provided on October 30, 2020.

You asked the Plan to pay for the dental service. You say that this service should be covered under your dental rider. You say that this service was a procedural exam that was required as part of a root canal. The Plan denied your request. The Plan says cone beam CT capture with interpretation for less than one whole jaw 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 cone beam CT capture with interpretation for less than one whole jaw (D0364) provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ophthalmic diagnostic imaging provided from February 26, 2020, to November 16, 2020.

You asked the Plan to waive the copayments for ophthalmic diagnostic imaging. You say that you disagree with the diagnostic copayments and feel that you should only owe a specialist copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for diagnostic procedures or tests. 

You received ophthalmic diagnostic imaging on February 26, 2020, and November 16, 2020. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe for ophthalmic diagnostic imaging is: $80. 

You have been asked to pay the total copayment amount of $80 for ophthalmic diagnostic imaging. Ophthalmic diagnostic imaging falls 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 copayments for ophthalmic diagnostic imaging provided from February 26, 2020, to November 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from August
29, 2020, to August 31, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this should be resubmitted with the correct bill type.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

The claim was submitted with an invalid type of bill. Based on this information, we decided that Medicare
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay
for home health services provided to the enrollee from August 29, 2020, to August 31, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS system for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the clinical value and effectiveness of the CaredioMEMS device in the setting of Congestive Heart Failure has not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. The Food and Drug Administration has stated that the CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. 

In this case, the enrollee has had a three-vessel coronary artery bypass and has ischemic cardiomyopathy with an ejection fraction of 17%. He was hospitalized in February 2021 for heart failure. The medical record indicates that he is NYHA class III. Our physician reviewer found that the enrollee's condition meets criteria for coverage of 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 been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS system for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-area ophthalmologist.

You asked the Plan to pre-approve these services. You say that you need to travel to Jacksonville and cannot travel to the Plan facility. The Plan denied your request. The Plan says the services are not urgent or emergent and are available from network providers.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 

We looked at this the file and Medicare rules. The file shows that you are leaving the Plan's service area with a known need for Eylea injections. The services are not for an unforeseen illness or injury. 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 referral to an out-of-area ophthalmologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided October
6, 2020.

You asked the Plan to pay for the pneumatic compression device. You say that you would like this claim
reprocessed for medical necessity. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device coded as E0675
is only used for PAD and this device is not eligible for reimbursement.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not
have to pay for the pneumatic compression device (E0675) provided October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x4, D7140 x6), and alveoloplasty (D7310 x2) provided on May 27, 2020.

You asked the Plan to pay for extractions, and alveoloplasty. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions, and alveoloplasty have not been met. Specifically, services were provided by an Opt out provider. The Plan does not cover dental services when provided by an Opt out provider. Therefore, we decided that the Plan does not have to pay for extractions (D7210 x4, D7140 x6), and alveoloplasty (D7310 x2) provided on May 27, 2020.