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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 5, 2021.

You asked the Plan to pay for the dental service. You say that this visit was to obtain a second opinion. You say that you did not lied the first office you went to. You say that they were up charging for the services that you needed. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit 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 comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on October 19, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy (90834) provided on March 5,2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. 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 individual psychotherapy (90834) provided on March 5,2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided by the out of network (OON) provider on August 22, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided by the out of network (OON) provider on August 22, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance and ground ambulance transportation provided on October 30, 2020.

You asked the Plan to pay for ambulance services. You say that this transport was needed so the enrollee could receive hospice services with her family, but the financial burden is significant. The Plan denied your request. The Plan says that these services were not medically necessary.

The Plan follows Medicare rules. Medicare pays for ambulance services only when they are medically reasonable and necessary. Medicare pays for air ambulance services only if the enrollee's medical condition is such that transportation by ground ambulance is not appropriate.

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 ambulance services. Our reviewer says that these services meet the Medicare criteria for coverage. Our physician reviewer found the enrollee had end stage metastatic carcinoma with altered mental status noted on her medical records due to brain metastases and pain control medication. She required medical monitoring of her vitals and would not be stable for transport in a non-medical vehicle. The enrollee's condition contraindicated transportation by any means other than ambulance, and for the air ambulance portion of the trip the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transport by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance services have been met. Therefore, we decided that the Plan has to pay for air ambulance and ground ambulance transportation provided on October 30, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the alginate dressing (A6196), the non-waterproof tape (A4450), and the sterile gauze (A6402) rendered by the out of network (OON) provider on July 8, 2020.

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the alginate dressing (A6196), the non-waterproof tape (A4450), and the sterile gauze (A6402) rendered by the out of network (OON) provider on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 9, 2020.

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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274), prophylaxis (D1110), and amalgam (D2150) provided on January 11, 2021, and January 27, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewings, prophylaxis, and amalgam. You say that you would like these services to be covered. The Plan denied your request. The Plan says the total liability amount of $259.00 was applied correctly. The Plan also says that enrollee liability is a contractual obligation under the Plan and cannot be waived.

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, you are responsible for the difference between the billed amounts and allowed amounts. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings (D0274), prophylaxis (D1110), and amalgam (D2150) provided on January 11, 2021, and January 27, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110), periodic oral evaluation (D0120), panoramic x-ray (D0330) and sales tax (D9985) provided on January 6, 2021.

You asked the Plan to pay for the dental services. You say that you should have a $0 copay for these services and the Plan should pay the full bill. The Plan denied your request. The Plan says When you use an out-of-network provider, you may be billed for any amount that the provider bills that is greater than the payment made by the Plan. You used an out-of-network provider. Sales tax is also not covered by the Plan under any circumstances.

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 sales tax (D9985) for the services provided on January 6, 2021.

The rules also 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 $0 copayment for dental cleanings, panoramic x-rays, and periodic oral evaluations. For services obtained out-of-network, the Plan only pays up to a certain amount. If you choose to see an out-of-network provider you might be billed for any amount greater than what the Plan pays, even for services listed as a $0 copayment.

You have been asked to pay $208 for the three covered dental services (excluding sales tax). The provider billed the Plan a total of $334 for these services, however the Plan's maximum allowable charge for the three services totals $126. In-network providers have agreed to be paid the Plan's maximum allowed amount, however out-of-network providers do not have this agreement. The Plan paid the full allowed $126 amount for these services, which left you with a $0 copayment responsibility on the maximum allowed charge. However, you are also responsible for any amount the provider billed that is greater than the Plan's maximum allowable charge ($334 - $126 = $208). 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 pay any additional amount for the cleaning (D1110), periodic oral evaluation (D0120) and panoramic x-ray (D0330) provided on January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on February 8, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $5 copayment for in-network outpatient laboratory services at a primary care physician (PCP) office.

Review of the file shows that you received laboratory services at your PCP's office on February 8, 2021. You have been asked to pay a $5 copayment for these services. These services fall within the in-network outpatient laboratory services at a primary care physician (PCP) office 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 laboratory services rendered on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on December 29, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit for a medical exam.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services (99203) provided on October 14, 2020.

You asked the Plan to pay for the dermatology services. You say that the services were medically necessary. The Plan denied your request. The Plan says there was no prior authorization. There were 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 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 services at issue in this appeal. The Plan did not pre-approve the service 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 dermatology services (99203) provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments for the paravertebral facet joint injection (64493) and the sacroiliac joint injection (G0260) provided on December 7, 2020 and December 18, 2020.

You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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). Your contract with the Plan clearly says that you must pay a $175 copayment per visit for surgery performed in an ambulatory surgical center or in an outpatient hospital facility. 

You have been asked to pay $350 ($175 copayment x 2) for the outpatient surgery provided in an ambulatory surgical 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 adjust the copayments for the paravertebral facet joint injection (64493) and the sacroiliac joint injection (G0260) provided on December 7, 2020 and December 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after May 21, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says SNF care is no longer 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 61-year-old male with a past medical history of depression, gout and neurogenic bladder who presented to the acute hospital on April 29, 2021, for weakness and a fall after treatment for esophageal cancer. He was treated in the hospital and transferred to a skilled nursing facility on May 3, 2021. His last covered day in the skilled nursing facility for skilled nursing and therapy services was May 21, 2021. Although the enrollee appears to need skilled therapy services, based on the medical records provided there is no documentation that the patient requires skilled nursing services. In addition, skilled services are not needed on a daily basis. Finally, this patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health or in a long-term care facility on a part time basis appear appropriate in this case.

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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) after May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your needs are not complex enough to require close supervision by a rehab physician.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you were admitted to the acute care hospital for surgery of a small bowel obstruction. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided by an out-of-network provider on July 7, 2020.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the physician provided medically necessary services and the claim should be processed for payment. The Plan denied your request. The Plan says in-network providers were 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 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 psychiatric diagnostic evaluation provided by an out-of-network provider on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiothoracic surgery services to be provided by an out of network provider.

You asked the Plan to pre-approve cardiothoracic surgery services. You say that the requested cardiothoracic surgeon is contracted. The Plan denied your request. The Plan says there are numerous in-network providers within network adequacy guidelines of 40 miles.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cardiothoracic surgery services to be provided by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires close daily oversight by a physician in an inpatient setting. The Plan denied your request. The Plan says the enrollee would be better suited in a less intensive therapy program.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of distal femur and distal humerus after a fall. Her medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.