Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on December 3, 2019 billed with codes 97010 and 97014.

You asked the Plan to pay for the therapy services as billed. You say that these services were denied incorrectly. The Plan denied your request. The Plan says the two codes that remain denied are not payable by Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code 97010 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is always bundled into payment for other services rendered on the same date of service. Code 97014 has a status indicator of "I".

This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the therapy services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on December 3, 2019 billed with codes 97010 and 97014.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a porcelain crown (D2750), provided on January 14, 2021.
You asked the Plan to pay for a porcelain crown. You say that the service should be covered. The Plan denied your request. The Plan says the service provided is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a porcelain crown (D2750), provided on January 14, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the NutrEval analysis and food allergy testing received on
March 26, 2019, the food allergy testing received on December 10, 2019, the Estrogen metabolism assessment
testing provided on May 21, 2020, the NutrEval analysis test received on February 8, 2021, by OON providers.

You asked the Plan to pay for the NutrEval analysis, food allergy testing, and the Estrogen metabolism
assessment testing. You say that you feel these services should be covered. The Plan denied your request. The
Plan says the services received are not a covered benefit when provided 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 the NutrEval analysis and food allergy testing
received on March 26, 2019, the food allergy testing received on December 10, 2019, the Estrogen metabolism
assessment testing provided on May 21, 2020, the NutrEval analysis test received on February 8, 2021, by
OON providers.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met because the requested services are not medically necessary.

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 that the enrollee appears to be unstable and requires short-term additional acute care services which can be safely be administered 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471) and removal of torus palatinus (D7472).

You asked the Plan to pre-approve removal of lateral exostosis and removal of torus palatinus. You say that this request is medically necessary to help your condition. The Plan denied your request. The Plan says these services are not covered under the member's benefit package.

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 pre-approve removal of lateral exostosis (D7471) and removal of torus palatinus (D7472).
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 you cannot be sent home as you do not have anyone available to give you the care you require. You need IRF care to regain your independence. The Plan denied your request. The Plan says your medical condition requires further evaluation and treatment in the acute care hospital. You must complete your full course of acute hospital treatment before another level of care will be considered.

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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on February 10, 2020.

You asked the Plan to waive the coinsurance for the aflibercept injection. You say that this is a necessary medical procedure that should be covered under your insurance. You say that you are only required to pay a copayment and are appealing the balance. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug from an in-network provider.

You have been asked to pay $380.99, which is 20% of the allowed amount for the aflibercept injection. The allowed amount is $1,904.94 (20% x $1,904.94 = $380.99). The aflibercept 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 coinsurance for the aflibercept injection provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on February 4, 2021.

You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says the exam was a Medicare-covered exam.

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 $25 copayment for Vision Care, Medicare-covered exams. 

You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the Vision Care, Medicare-covered exams 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 eye exam provided on February 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 30, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, 
fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.

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 physician's services provided on March 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 28 additional one-way trips for the benefit year.

You asked the Plan to pre-approve additional trips. You say that you just got out of the hospital and need to see your doctor. The Plan denied your request. The Plan says your benefit only allows 36 trips for the service at issue.

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 a maximum of 36 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan is benefit is limited to 36 one-way trips per year. The case record indicates that you have 1 one-way trip left before you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 28 additional one-way trips for the benefit year.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 13, 2021.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

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 February 13, 2021. 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 provided on February 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sleep Number bed and accessories purchased June 26,
2020.
You asked the Plan to pay for the Sleep Number bed. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says this bed was not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the Sleep Number bed and accessories purchased June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord stimulation.
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed other treatments. The Plan denied your request. The Plan says it is used only when all other treatments have failed.
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulation is only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. He is taking Tramadol and Gabapentin for pain. He has tried physical therapy and chiropractic therapy. He had an epidural steroid injection, which produced 80% pain relief. His MRI shows a disc protrusion at L5-S1. He has not had any surgery. The enrollee does not have an evidence-based indication for a SCS trial. Therefore, the request is not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal cord stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided on July 10, 2019, to July 12, 2019.

You asked the Plan to waive the deductible for inpatient hospital care. You say that you feel like the deductible should be waived because they are billing for this deductible two years later. You also say that you are on a fixed income and cannot pay this bill. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible for inpatient hospital care.

The EOC shows that you pay a deductible of $300 per year, for covered services received in a general acute care hospital. The EOC also confirms that you will not pay more than $300 for inpatient hospital covered services in a calendar year. At the time this claim was processed, $0 of the $300 deductible had been met. The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital care was received on July 10, 2019 to July 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital care provided on July 10, 2019, to July 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. 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 care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require daily skilled nursing or therapy at an inpatient level. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment charged for a specialist office visit. We decided that the Plan may charge a copayment for a primary care provider office visit.

You asked the Plan to waive the copayment for the office visit. You say that since you had had an ultrasound during this visit, the copayment for the ultrasound should be the only cost sharing you have to pay. The Plan says that you were charged this copayment correctly.

We decided that the Plan has to waive the copayment charged for a specialist office visit.

The Plan has an obligation to charge copayments in accordance with their Evidence of Coverage. In this case, the provider with whom you had this office visit is listed in the case file the Plan submitted to us as your Primary Care Provider (PCP). In other words, this doctor is not a specialist. That is why it is not appropriate for the Plan to assess a specialist copayment for this service visit. Therefore, we decided that the Plan has to waive the copayment charged for a specialist office visit.

We also decided that the Plan may charge a copayment for a PCP visit.

As noted above, in the Plan's case file submitted to us, they have indicated that the provider with whom you had this office visit is your PCP. Under the terms of your Evidence of Coverage, it states that you pay a $10 copayment for each visit with your PCP. There is no provision in your contract for a waiver of this amount if you receive testing or other services during the visit for which other cost sharing may apply. Therefore, we decided that the Plan may charge a copayment for a PCP visit.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the home ventilator.

You asked the Plan to pre-approve home ventilator, any type, used with non-invasive interface (E0466). You say that the enrollee is receiving good benefit from the device. The Plan denied your request. The Plan says the requested device is being used in the bilevel positive airway pressure mode rather than being used as a home ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 home ventilator, any type, used with non-invasive interface (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found this patient has been given a diagnosis of chronic obstructive pulmonary disease, but the records do not include pulmonary function tests to confirm. The patient is morbidly obese and has obesity hypoventilation syndrome; the appropriate treatment for this is continuous positive airway pressure or bilevel positive airway pressure (BiPAP). There is no evidence of BiPAP failure. The patient is not using the ventilator enough for it to be effective. Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home ventilator, any type, used with non-invasive interface (E0466) have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of the home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on March 5, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you wanted a second opinion because you doubted you had gingivitis. You also say the Plan said you
could get a second opinion. The Plan denied your request. The Plan says these services exceed the frequency
limitation in your benefit plan. The Plan also says that no prior calls in the call history were found where you
asked for a second opinion, or about any of your dental 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, comprehensive oral evaluation
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of
intraoral x-rays (D0210) on January 21, 2020, and your comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210)
provided on March 5, 2021.