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

We decided that the Plandoes not haveto pay foroffice visit services provided to the enrollee on August 22, 2019.You asked the Planto pay forthe services. You say that you were unaware that you were out-of-network.The Plandenied your request. The Plansaysenrollees must use network providers.Medicarerules 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 Plandoes not haveto pay foroffice visit services provided to the enrollee on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on June 27, 2019.You asked the Plan to pay forthe dental services. You say that you had been advised that there was an unknown mass in your right sinus cavity. You state you had sinus surgery, but still had inflammation and was advised to see an endodontist. You state that you were advised that you needed to have a previous root canal repaired to treat the sinus inflammation, but you elected to have the tooth pulled. You state these dental services should be reviewed under your medical plan.The Plan denied your request. The Plan says the services performed are dental in nature, not medical.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.CMS guidelines clearly state that Medicare-covered dental services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that wouldbe covered when provided by a physician. The services performed are dental in nature, not medical.Your EOC clearly states that you have a maximum dental allowance amount of $900 for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services. Your EOC clearly states that you are responsible for any amount of dental services over the maximum dental allowance amount. A review of your claims shows that the Health Plan has paid you the $900 dental allowance. The Health Plan is not going to issue any further payment for the dental services as the services are not Medicare-covered dental services and you have already been reimbursed the full amount of the dental allowance for non-Medicare covered dental services.Therefore, we decided that the Plan does not have to pay forthe dental services provided on June 27, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvepositron emission tomography (PET) and computed tomography (CT) scan services.You asked the Plan to pre-approvethe PET/CT scan services. You say that the records provided support the need for the requested PET/CT scan.The Plan denied your request. The Plan says that the requested study would exceed the allowed limit of three scans for the enrollee's cancer type in order to allow for the doctor to planfurther treatment.The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT scan services. Our reviewer says that the requested PET/CT scan is medically necessary. Our physician reviewer found the enrollee has multiple prior lines of therapy for metastatic cervical cancer and had a recent CT scan on February 27, 2020 that was suggestive of progression of disease. The enrollee's last PET scan was in September of 2019 and did not show these changes. A PET scan would allow further evaluation of not onlythe pelvic findings (which may be FDG avid base on recent infection but treated and nearly 4 weeks out) but also the new 1.4 cm right lower lobe lung nodule. Restaging with a PET scan given recent CT findings is required to determine further treatment strategies.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 PET/CT scan services have not been met.Therefore, we decided that the Plan has to pre-approvepositron emission tomography (PET) and computed tomography (CT) scan services.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 informationto 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: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on July 9, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the service billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forextraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 5, 2018.You asked the Plan to pay forthe dental services. You say that you sustained a traumatic injury to your face and mouth and were not aware this would not be paid.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay forextraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 5, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forradiology services (CPT 75635) provided to the enrollee on October 22, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis was denied as it did not include the appropriate primary, first-listed or principal diagnosis.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 75635 is "Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including non-contrast images, if performed, and image postprocessing."We find that CPT code 75635 is not supported in the medical record. Specifically, this code was not billed with an appropriate principal diagnosis. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forradiology services (CPT 75635) provided to the enrollee on October 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe radiation therapy provided from August 9, 2019 to August 30, 2019.You asked the Plan to waive the coinsurance forthe radiation therapy. You say that it was your understanding from the beginning that the services were all taken care of when you asked the people at the facility.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 radiation therapy (office visit copayment may apply). You have been asked to pay a total of $1,284.29 for the radiation therapy. The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.  Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityAugust 9, 2019Hospital outpatient clinic$135.68N/A$0August 14, 2019Therapeutic radiation simulation$144.6320%$28.99August 14, 2019Radiation treatment$144.6320%$28.99August 14, 20193-D radiotherapy plan$1,395.9520%$279.19August 20, 2019Radiation therapy dose plan$869.7620%$173.95August 20, 2019Radiation treatment$376.9120%$75.38August 20, 2019Radiation treatment$1,884.5520%$376.91August 23, 2019Set radiation treatment field$144.9620%$28.99August 26, 2019Radiation treatment delivery$262.8820%$52.58August 27, 2019Radiation treatment delivery$262.8820%$52.58August 28, 2019Radiation treatment delivery$262.8820%$52.58August 29, 2019Radiation treatment delivery$262.8820%$52.58August 30, 2019Radiation physics consult$144.9620%$28.99August 30, 2019Radiation treatment delivery$262.8820%$52.58Total$1,284.29This 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe radiation therapy provided from August 9, 2019 to August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forsurgical tray and supplies provided to the enrollee on October 15, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysadditional or separate payment for these supplies is not a covered benefit.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 definition of HCPCS codes A4550 and A0270 are:A4550:surgical traysA0270:medical/surgical supplies and devices -generalWe find that the denied HCPCS codes are not supported in the medical record. Specifically, payment for supplies during a surgical procedure are included in the payment for the procedure. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forsurgical tray and supplies provided to the enrollee on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forpodiatry services provided on November 14, 2019.You asked the Plan to waive the deductible forpodiatry services. You say that the podiatrist did not do anything at all and disagree with the charges.The Plandenied 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. Your contract with the Plan says that there is a $750 deductible for podiatry services. The medical records show that you received podiatry services on November 14, 2019. The record shows that you had only paid $422.46 toward the $750 deductible at the time services were received. Therefore, you are responsible to pay the allowed amount of $106.65.The item or service you asked the Plan to waive the deductible for falls within the benefit category podiatry services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for podiatry services. This cost sharing is a contractual obligation that had not been met at the time podiatry services was received on November 14, 2019.Therefore, we decided that the Plan does not have to waive the deductible forpodiatry services provided on November 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee on June 28, 2019 by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says authorization for out-of-network services was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided to the enrollee on June 28, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the enrollee's care can be provided in the current inpatient hospital.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's ongoing care needs include respiratory support with oxygen supplementation, nebulizer treatments, infectious contact precautions, oral antibiotics, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe medical eye exam provided on December 11, 2018.You asked the Plan to waive the copayment forthe medical eye exam. You say that you should not be responsible for the copayment because the doctors said they would take care of it. 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 a $40 copayment for each Medicare-covered eye exam (diagnosis and treatment for diseases and conditions of the eye). You have been asked topay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows a diagnosis of age-related cataracts which makes the exam medical in nature.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 forthe medical eye exam provided on December 11, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services arenecessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cataract surgery provided on December 9, 2019.You asked the Plan to waive the copayment forthe cataract surgery. You say that this was a quick office procedure and you feel like the $400 copayment is too much. You say it was your understanding that the procedure would be covered. 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 thatyou must pay a $400 copayment for Medicare-covered in-network outpatient hospital services. You have been asked to pay a $400 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.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 forthe cataract surgery provided on December 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe destruction of a skin lesion (17000) provided on November 12, 2019.You asked the Plan to waive the copayment forthe destruction of a skin lesion. You say that this should not be considered surgery.The Plan denied your request. The Plan says this service processed 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 $400 copayment for Medicare-covered outpatient hospital surgery services. You have been asked to pay a $329.88copayment for the destruction of a skin lesion. The destruction of a skin lesion falls within the Medicare-covered outpatient hospital surgery services benefit category.Because theallowed amount is less than your copayment, 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 forthe destruction of a skin lesion (17000) provided on November 12, 2019.