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

We decided that the Plan does not have to pay for the oral exam (D0120) provided on August 19, 2019 by an out of network provider.You asked the Plan to pay for the dental service. You say that you received a pre-authorization dated February 7, 2020 for this claim that said the Plan would pay $140 for the services.The Plan denied your request. The Plan says any services that you receive from an out of network provider are not covered. The Plan says the authorization you received dated February 7, 2020 is based on your 2020 benefits. The Plan also says that the services were received in 2019 and therefore processed based on your 2019 coverage.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 oral exam is listed as covered, dental services that you receive out of network are not covered. The record shows that you received the oral exam in 2019 and were therefore processed based on your 2019 dental coverage.Therefore, we decided that the Plan does not have to pay forthe oral exam (D0120) provided on August 19, 2019 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on November 19, 2019.You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charge 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 $295 copayment, for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $295 copayment, for an EGD. An EGD falls within the outpatient surgery and other medical 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 an EGD provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on December 16, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care with oxygen supplementation and secretion suctioning, telemetry, 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. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care with oxygen supplementation and secretion suctioning, telemetry, 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 17, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora seat lift mechanism provided on October 28, 2019. You asked the Plan to pay for a seat lift mechanism. You say that this was approved by your surgeon. The Plan denied your request. The Plan says this is not part of a course of treatment. The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 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 a seat lift mechanism. Our reviewer says that the criteria for coverage of this item have not been. Our physician reviewer found the documentation does not reveal objective imaging studies of severe arthritis of the hip or a neuromuscular disease. The records do not indicate a seat lift is included in the treating practitioner's course of treatment. The seat lift is not likely to affect improvement in your condition or slow deterioration in your condition. The records do not show that you are completely incapable of standing from a chair in the home. There is no objective gait evaluation indicating you have the ability to ambulate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism provided on October 28, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 4 home health skilled nursing visits. 
 
You asked the Plan to pre-approve the additional home health skilled nursing visits. You say that you would like to keep the enrollee out of the wound clinic during Covid-19. The Plan denied your request. The Plan says the documents do not support the approval for 4 additional visits. The Plan also says that the documentation states that the enrollee prefers face to face follow up at the wound clinic. 
 
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 the additional skilled nursing visits. Our reviewer says that the additional skilled nursing visits are not medically necessary. Our physician reviewer found the requested 4 home health skilled nursing services are not required to effectively provide treatment, care, and/or services which are medically necessary for the patient. Our reviewer found that while the enrollee needs continued wound monitoring, the documentation indicates that the enrollee prefers face to face clinic follow up 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 additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 4 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the radiation therapy provided from December 20, 2019 to December 26, 2019. 
 
You asked the Plan to reduce the coinsurance for the radiation therapy. You say that you were told that the provider was allowed to bill for three radiation treatments was just over $1,000 each. You say you are being charged 30% of the amount. 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 at an in-network outpatient hospital.  
 
You have been asked to pay $324.93 which is 20% of the allowed amount for each of the radiation therapy. The allowed amount is $1,624.64. ($1,624.64 x 20% = $324.93) ($324.93 x 3 dates of service = $974.79). The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for the radiation therapy provided from December 20, 2019 to December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Relion Prime test strips.You asked the Plan to pre-approve diabetic testing strips. You say that due to the amount of insulin the enrollee is taking, he needs to test his blood sugar 4 to 5 times per day.The Plan denied your request. The Plan says the denial of authorization for additional test strips is correct, because the Plan has already approved 200 strips per 30 days and the requested 400 strips per 30 days is not necessary.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 diabetic testing strips. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, 400 test strips per 30 days is not medically reasonable and necessary. Testing 5 to 6 times per day would require up to 180 strips per 30 days, which is less than the amount the Plan has already approved.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic testing strips have not been met.Therefore, we decided that the Plan does not have to pre-approve additional Relion Prime test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit (E0720) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve a TENS unit. You say that you are appealing denial for coverage as you would like the unit to strengthen quad and knee muscles.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan has confirmed the requested service is available in-network. Coverage for this device is also limited to 30 days from the day of surgery therefore, coverage criteria has not been met. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) unit (E0720) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on September 9, 2019.
You asked the Plan to pay for the services provided. You say that the enrollee needed medical services due to right sided weakness and altered mobility. The Plan denied your request. The Plan says the records indicate an evaluation by a licensed physical therapist did not occur.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the services at issue are not supported in the medical record. Specifically, the records do not indicate that a qualified therapist, instead of an assistant, was present to perform the ordered therapy services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve these services. You say that this provider is your family's longstanding
doctor. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network orthopedic surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided on December 15, 2019 to December 21, 2019 by an out of network (OON) provider. You asked the Plan to pay for OON personal care services. You say that these services were authorized.The Plan denied your request. The Plan says there is not a valid authorization for these dates. 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 personal care services provided on December 15, 2019 to December 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services received on January 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says if you file a claim with your Plan, you will not be reimbursed.
The Plan must follow Medicare rules. The rules say that Medicare does not cover eye refraction
The services you asked the Plan to pay for are considered eye refraction. Therefore, we decided that the Plan
does not have to pay for eye refraction services received on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the low osmolar contrast material coded Q9967 provided on August 21, 2019. 
 
You asked the Plan to pay for the low osmolar contrast material. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. 
 
We find that CPT code Q9967 is not supported in the medical record. Specifically, 140 units of this code were billed. The documentation submitted does not support the units billed. The documentation submitted indicates that 120ml contrasts was administered. Therefore, this service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the low osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay for the low osmolar contrast material coded Q9967 provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 16, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture and a partial lower denture. You asked the Plan to pre-approve the dental items. You say that the partial dentures are necessary for the enrollee. The Plan denied your request. The Plan says the requested partial dentures are not medically necessary. The Plan also says the remaining teeth have a poor prognosis. 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. The Plan covers the dental items when the services are medically necessary and reasonable. 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 dental items. Our reviewer says that the partial dentures are not medically necessary. Our physician reviewer found the provided documentation indicates that the remaining upper and lower teeth which would be used for support and retention of the partials have a poor prognosis. Therefore the reviewer found that the partial dentures are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental items have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture and a partial lower denture.