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

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided July 31, 2019 to August 29, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided July 31, 2019 to August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the incomplete endodontic therapy. We decided that the Plan does not have to pay for the problem focused limited oral evaluation.
You asked the Plan to pay for the problem focused limited oral evaluation and incomplete endodontic therapy. You say that the provider was in-network according to Medical Mutual, their receptionist, and the provider's receptionist. You also say that the provider's office stated that the remainder of the cost would be paid by Medical Mutual. The Plan says that the records show that you did not contact the Plan and inquire about your dental benefits prior to the services being rendered. The Plan also says that the problem focused limited oral evaluation and incomplete endodontic therapy are non-covered services.
We decided that the Plan has to pay for the incomplete endodontic therapy.
The Evidence of Coverage clearly states that one visit for an endodontic (root canal) service per calendar year is covered and you are responsible for a 50% coinsurance. The contract language does not clearly state which endodontic services are covered by the Plan. Therefore, we decided that the Plan has to pay for the incomplete endodontic therapy.
We also decided that the Plan does not have to pay for the problem focused limited oral evaluation.
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation is not included on this list and is not a covered supplemental benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography provided on July 17, 2018 by out of network provider.
You asked the Plan to pay for the screening mammography. 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 has network providers available who can provide 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 screening mammography provided on July 17, 2018 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2018 by out of network provider.
You asked the Plan to pay for radiology services. You say that you would like the claim reprocessed and approved for payment. The Plan denied your request. The Plan says there is no valid referral for this service.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 17, 2018 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on June 26, 2019.
You asked the Plan to pay for the laboratory testing. 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on June 26, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit injections (J0885).
You asked the Plan to pre-approve the Procrit. You say that the Procrit injection is medically necessary. The Plan denied your request. The Plan says the step therapy exception criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Procrit. Our reviewer says that provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found the provided medical records do not indicate that the member has tried and failed Retacrit.
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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit injections (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and bitewings provided on August 13, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and bitewings. You say that this should be paid for because you have not had a full mouth x-ray in 2 years. The Plan denied your request. The Plan says under this dental coverage, benefits can be provided for this service only once per benefit year. The Plan also says that the limit for these benefits have been exceeded.
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 limited to one exam per calendar year including: one set of bitewing x-rays per calendar year and one cleaning per calendar year. The record shows that you received an oral evaluation (exam) and bitewing x-rays on February 28, 2019 and your exam and bitewing x-rays benefits were then exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and bitewings provided on August 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT Scan of the heart (75571).
You asked the Plan to pre-approve the CT Scan. You say that the CT Scan is preventative because you have a family history of cardiac conditions. The Plan denied your request. The Plan says the submitted medical records do not document any medically indicated need for this test.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT Scan. Our reviewer says that you do not meet Medicare coverage criteria for the CT Scan. Our physician reviewer found your cardiac risk is below average and you are asymptomatic. A family history of myocardial infarction without any other positive factors is not a valid indication for medical necessity of the requested test. 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 CT Scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT Scan of the heart (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, pulp vitality tests, cone beam CT capture and interpretation, and incomplete endodontic therapy provided on August 1, 2019.
You asked the Plan to pay for the first intraoral periapical x-ray, pulp vitality tests, cone beam CT capture and interpretation, and incomplete endodontic therapy. You say that according to the 2019 Plan coverage package that was provided, this provider was listed as the only endodontic provider. The Plan denied your request. The Plan says the first intraoral periapical x-ray and incomplete endodontic therapy are not covered because you exceeded the allowed benefit limitation for these services. The Plan also says that pulp vitality tests and cone beam CT capture and interpretation are not covered 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, the pulp vitality tests and cone beam CT capture and interpretation are not covered under this benefit. The contract also clearly states that intraoral x-rays are limited to one set per calendar year and root canals are limited to one procedure per calendar year. The record shows that you received an additional intraoral periapical x-ray on August 1, 2019 and retreatment of previous root canal therapy on August 13, 2019 and your intraoral x-rays benefit and root canal benefit were then exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, pulp vitality tests, cone beam CT capture and interpretation, and incomplete endodontic therapy provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on December 3, 2018.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. 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 directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the physician services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the physician services provided on December 3, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two further physical therapy (PT) visits.
You asked the Plan to pre-approve these services. You say that your arm is still very stiff and you cannot extend it to full capacity. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records show that you have a diagnosis of an incomplete rotator cuff tear in the left shoulder. You underwent arthroscopic surgery on August 28, 2019. The PT note dated November 1, 2019 states you have an improved range of motion (ROM) to 90. You were given a home exercise program. The records do not support that two further PT visits would likely result in further improvement in your ROM. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve two further physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on October 8, 2019.
You asked the Plan to pay for the intraoral x-rays. You say that your provider checked and told you that an exam, cleaning, and x-rays were covered by your plan. You also say that you called the Plan prior to the appointment and were told that these services would be covered. The Plan denied your request. The Plan says you were not enrolled in the supplemental dental package and you only had the embedded dental plan. The Plan also says that this service is excluded from the embedded dental 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, only one set of bitewing x-rays are covered by the Plan. The record shows that you received a complete series of intraoral x-rays and this service is not listed as a covered benefit. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the portable oxygen provided on July 5,
2019.
You asked the Plan to waive the coinsurance for the portable oxygen. You say that you have never had to pay
for oxygen supplies before and you do not agree with being charged. The Plan denied your request. The Plan
says you have been charged the correct cost sharing 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 20%
coinsurance for DME and related supplies.
You have been asked to pay $13.28 which is 20% of the allowed amount for the portable oxygen. The allowed
amount is $66.38. ($66.38 x 20% = $13.28). The portable oxygen falls within the "Durable medical equipment
(DME) and related 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 coinsurance for the
portable oxygen provided on July 5, 2019.
Our decision is only about the July 5, 2019 service. If you have any questions about prior years billing, please
contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on April 9, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted documents that less than 30 minutes of hospital discharge day management services were rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the record. Specifically, the record indicates that less than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on April 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on September 4, 2019.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a colonoscopy screening and you disagree with the charges. 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 $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had a colonoscopy on September 4, 2019 due to a heme positive stool. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $450 copayment. You have been asked to pay a $450 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a diagnostic colonoscopy provided on September 4, 2019.
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 the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. Our physician reviewer found based on review of the available records, you do not meet criteria for coverage for an admission to an IRF. You were medically stable, no medical complexity with no evidence of need for supervision by acute physical medicine and rehabilitation (PMR) or acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ambulance trip and ER visit provided on August 6, 2019.
You asked the Plan to waive the copayments for an ambulance trip and ER visit. You say that you cannot
afford the charges. 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 $150
copayment for ambulance services. Your contract also clearly says that you must pay a $75 copayment for
emergency care.
You had an ambulance trip on August 6, 2019. Therefore, you are responsible to pay the $150 copayment.
You had an ER visit on August 6, 2019. Therefore, you are responsible to pay the $75 copayment.
The total amount you owe is: $225.00.
You have been asked to pay the total copayment amount of $225.00 for an ambulance trip and ER visit. An
ambulance trip falls within the ambulance services benefit category. An ER visit falls within the emergency
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 copayments for an ambulance trip and ER visit
provided on August 6, 2019.