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

We decided that the Plan does not have to pay for the laboratory services provided on April 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services provided on April 12, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 16, 2021, to March 2, 2021.
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from July 13, 2020, to February 15, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 16, 2021, to March 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is 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 that no required skilled nursing services are identified. The enrollee does require skilled therapy services; however, the documentation does not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis in a skilled nursing facility on an inpatient basis. 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. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the genetic testing rendered on March 3,
2021.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the
coinsurance. The Plan denied your request. The Plan says the coinsurance was 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 a 20%
coinsurance for molecular or predisposition genetic testing.

Review of the file shows that you received genetic testing on March 3, 2021. You have been asked to pay a
20% coinsurance for these services. These services fall within the molecular or predisposition genetic testing
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 genetic testing rendered on
March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on
March 30, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $35 copayment for each in-person specialist visit.

The enrollee has been asked to pay a $35 copayment for the specialist visit provided. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the office visit (99203) provided on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scans (71260, 76376) provided on October 14, 2020.

You asked the Plan to pay for CT scans. You say that code 71275 was billed in error. The Plan denied your request. The Plan says these codes cannot be paid separately.

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, we have confirmed that codes 71260 and 76376 have a bundled relationship with code 71275 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) scans (71260, 76376) provided on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.

You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a comfort or convenience item.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided from March 10, 2021 to March 25, 2021.

You asked the Plan to pay for the inpatient psychiatric services provided from March 10, 2021 to March 25 2021. You say that the services should be covered. The Plan denied your request. The Plan says as of March 9, 2021 the enrollee was no longer a threat to themself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient psychiatric services provided from March 10, 2021 to March 25, 2021. Our reviewer says that the inpatient psych services are not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee was not shown to be a danger to herself or others. The reviewer found that the enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. Therefore, the reviewer found that the continuation of inpatient mental health treatment was 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 inpatient psychiatric services provided from March 10, 2021 to March 25, 2021, have not been met. Specifically, the file shows that the enrollee was not shown to be a danger to themself or others as of March 10, 2021. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric services provided from March 10, 2021 to March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested inpatient psychiatric care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer upon review of the records provided, it is not expected the enrollee would improve in a reasonable period of time as the enrollee does not have suicidal or homicidal ideation noted and denies any auditory or visual hallucinations. The enrollee is compliant with treatment while not showing any acute threats to safety. It does not appear that active treatment is taking place. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for actinotherapy, ultraviolet light B therapy
(96900) provided March 15, 2021.
You asked the Plan to waive the copayment for ultraviolet light therapy. You say that you do not believe a
charge for each treatment is appropriate. However, if a charge is necessary, it would be fairer to charge a lesser
amount. The Plan denied your request. The Plan says the claim was processed with the correct copayment
applied per the Evidence of Coverage.
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
copayment for consultation, diagnosis and treatment by a specialist.
You have been asked to pay $20 copayment for ultraviolet light therapy. Ultraviolet light therapy falls within
the Physician/Practitioner services including doctor's office visit 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 actinotherapy, ultraviolet light B therapy (96900) provided March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group three power wheelchair (PWC) with multiple power options (K0861) and accessories.
You asked the Plan to pre-approve a group 3 PWC with multiple power options and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says you do not have a qualifying diagnosis causing mobility limitation.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. le does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve the group three power wheelchair (PWC) with multiple power options (K0861) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on December 29, 2020.

You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that you needed this treatment because of gum disease. You say that you were told this was covered and you cannot afford the bill. The Plan denied your request. The Plan says the service 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 the comprehensive periodontal evaluation (D0180) provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for cryosurgical ablation of the prostate.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.
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 provider for cryosurgical ablation of the prostate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fascial plication procedure (15830, 15847).

You asked the Plan to pre-approve a fascial plication procedure. You say that the requested procedure is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is cosmetic and not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 

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 a fascial plication procedure. Our reviewer says that the requested service is not medically necessary in this case. Our reviewer found that you have discomfort when leaning forward. The record indicates that you wish to reduce the upper abdominal protuberance. The record does not indicate that this interferes with activity. The record suggests that the requested procedure is not being performed to repair an injury or improve functioning of a malformed body member. The elements of the coverage criteria are not satisfied. 

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 fascial plication procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a fascial plication procedure (15830, 15847).
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

We decided that the Plan has to pay for the services rendered from February 17, 2020, to June 30, 2020. We decided that the Plan does not have to pay for the services rendered from January 7, 2019, to November 4, 2019.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan says that the claim was not filed timely.

We decided that the Plan has to pay for the outpatient mental health services rendered from February 17, 2020, to June 30, 2020.

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. The Plan states that the claim was not filed timely; however, the file shows that the claim was received on February 3, 2021. This means that the claim for services rendered from February 17, 2020, to June 30, 2020, was received within one year of the dates of service. Therefore, we decided that the Plan has to pay for the outpatient mental health services rendered from February 17, 2020, to June 30, 2020.

We also decided that the Plan does not have to pay for the outpatient mental health services rendered from January 7, 2019, to November 4, 2019.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for these services was not filed until February 3, 2021. This means that more than one calendar year from the date of service had passed before a claim for services from January 7, 2019, to November 4, 2019, was filed. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered from January 7, 2019, to November 4, 2019.

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 pre-approve a consult with an endodontist and a root canal on tooth #29.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist.
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 services when the services are provided by a participating general dentist. The requested dental services are to be performed by an endodontist. This provider type is not covered by your dental plan. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a consult with an endodontist and a root canal on tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image - image capture only (D0701) provided March 30, 2021.

You asked the Plan to pay for the panoramic x-ray - image capture only. You say that the dentist encouraged you to get x-rays even though you have never had dental problems. The Plan denied your request. The Plan says this service is not covered under your 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, 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 the panoramic radiographic image - image capture only (D0701) provided March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $450 copayment charged for outpatient surgery.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.

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 $450 copayment for outpatient surgery. 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 $450 copayment charged for outpatient surgery provided on October 14, 2020.