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

We decided that the Plan does not have to pay for knee arthroscopy (29877), and removal of support implant
(20680) provided on January 29, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for knee arthroscopy, and removal of support implant. You say that you want the
Plan to pay for the services at issue. The Plan denied your request. The Plan says the services were not referred
by a network provider or rendered in a participating facility. The services were not urgent or emergent and
were not approved of in advance.
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 knee arthroscopy (29877), and removal of support
implant (20680) provided on January 29, 2020 by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from February 17, 2021, through February 24, 2021, by an out-of-network provider.

You asked the Plan to pay for inpatient hospital care. You say that you are in-network. The Plan denied your request. The Plan says this facility is not in-network, and the enrollee was transferred from an out-of-network hospital to another out-of-network hospital without prior authorization on February 27, 2021.

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 inpatient hospital care provided to the enrollee from February 17, 2021, through February 24, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve MyOwn Skin, includes harvesting and preparation procedures.
You asked the Plan to pre-approve MyOwn Skin, includes harvesting and preparation procedures. You say that
the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been
established. Therefore, coverage criteria have not been met.
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 MyOwn Skin, includes harvesting and
preparation procedures. Our reviewer says that the requested items/services are considered medically
reasonable and necessary in this case. Our physician reviewer found based on the provided records and
statements this procedure meets medical necessity criteria as it is safe and effective, appropriate for you, and
not only for convenience.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MyOwn Skin, includes harvesting and preparation procedures have been met.
Therefore, we decided that the Plan has to pre-approve MyOwn Skin, includes harvesting and preparation
procedures.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the core build up (D2950) and porcelain crown (D2740) provided from December 30, 2020, to January 14, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you keep receiving bills for services that you were told would be covered. You say that it was not until after you received the services that the plan "changed their mind." You also say that you should not owe anything. The Plan denied your request. The Plan says there is a $425 allowance per quarter for comprehensive dental services. The Plan says that the unused portion of this allowance rolls over every quarter and what is unused at the end of the year is lost. The Plan says that the allowance for 2020 has been exceeded. The Plan also says that the allowance for the first quarter of 2021 has 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 and the services are listed as covered, the maximum benefit has been exhausted.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on January 5, 2021 to January 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the acupuncture services. You say that on 01/04/2021 a benefit check was done and it was not mentioned that the enrollee was HMO or that you are out of network. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 acupuncture services provided on January 5, 2021 to January 21, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health physical therapy (PT) visits.
You asked the Plan to pre-approve 4 additional home health PT visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 4 additional home health PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition or to improve function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), a panoramic radiographic image (D0330), a teeth cleaning (D1110), a filling (D2392), and intraoral periapical radiographic images (D0220, D0230) provided from March 19, 2021, through April 20, 2021.

You asked the Plan to pay for a periodic oral evaluation, bitewing radiographic images, a panoramic radiographic image, a teeth cleaning, a filling, and intraoral periapical radiographic images. You say that you want the Plan to pay for the services at issue. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider. The Plan also says that intraoral periapical radiographic images are 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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing radiographic images, a panoramic radiographic image, a teeth cleaning, a filling, and intraoral periapical radiographic images have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Additionally, intraoral periapical radiographic images are not a covered benefit. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), a panoramic radiographic image (D0330), a teeth cleaning (D1110), a filling (D2392), and intraoral periapical radiographic images (D0220, D0230) provided from March 19, 2021, through April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services you received on May 19, 2021.
You asked the Plan to waive the copayment for the urgent care services. You say that since the nurse at the urgent care center couldn't give you a cortisone shot, you do not think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $65 copayment for urgent care services. You have been asked to pay a $65 copayment for the urgent care services. This copayment applies regardless of the extent of services you receive at the urgent care center. 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 urgent care services you received on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for 14 units of infectious agent detection (87798) provided on October 5, 2020.

You asked the Plan to pay for infectious agent detection. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the billed units exceed the Medically Unlikely Edits (MUE).

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for infectious agent detection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found code 87798 has a MUE of 13 and a MUE Adjudication Indicator (MAI) of 3, meaning more than 13 units can be paid when they are medically necessary. However, the records show that this testing was done for screening purposes and was not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for 14 units of infectious agent detection (87798) provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit coded as 99215, 80050, 82607,
82746 and 83036 provided on July 21, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the receptionist verified the insurance but did not
see that there was another primary care physician. You are asking for the claim to be reviewed for payment.
The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted
providers require prior authorization before services being rendered. 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 outpatient office visit coded as 99215, 80050,
82607, 82746 and 83036 provided on July 21, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. 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. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the non-emergent ambulance transportation services (A0428, A0425)
provided on December 9, 2020.
You asked the Plan to pay for the non-emergent ambulance services. You say that these services were
medically necessary. The Plan denied your request. The Plan says that a physician's office, clinic, outpatient
clinic or outpatient surgery center is not a covered destination without immediate concern in non-urgent nonemergency
situations. These services were not medically necessary; van transportation or another vehicle may
have been an option. Therefore, payment is denied for these services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. We reached out to the Plan to obtain the necessary medical records, because the
case file indicated that medical records were provided to the Plan. We did not receive any records in the initial
case file or after outreach before the turnaround time for this case.
With the current COVID-19 public health emergency, the Centers for Medicare and Medicaid Services has
expanded the list of covered destinations for ambulance transportation to include physician's offices. No
records were forwarded to us to substantiate the Plan's claims that the services provided were not reasonable
and necessary. Therefore, we decided that the Plan has to pay for the non-emergent ambulance transportation
services (A0428, A0425) provided on December 9, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. The enrollee's needs can be met at a lower 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the
head you had on March 11, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that this CT scan should be covered
because your doctor ordered it due to tremors. The Plan denied your request. The Plan says you were charged
this copayment correctly. The Plan says that because the allowed amount for this CT scan ($114.48) is less
than your copayment obligation, you are responsible for the full allowed 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 $300
copayment for advanced imaging services.
You have been asked to pay a $300 copayment for the CT scan. The CT scan falls within the advanced imaging
services 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 the computed tomography (CT) scan of the
head you had on March 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on January 19, 2021 to February 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 pay for the home health services rendered on January 19, 2021 to February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) and strapping, Unna boot (29580) provided on April 3, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you went to this provider on an emergency basis. You had taken a fall and had a blood clot. Had they said they don't take your insurance you would have left because you can't afford to pay these kind of bills. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99203) and strapping, Unna boot (29580) provided on April 3, 2020 by an out-of-network (OON) provider.