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

We decided that the Plan does not have to pay for the hospital emergency room services.
You asked the Plan to pay for the hospital emergency room services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says no additional payment can be made for
this claim.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan
cannot be held responsible for the hospital emergency room services until the primary insurer has denied the
claim for these services. Review of the file shows that the enrollee's automobile insurance paid $5,000 toward
the bill for services received. Since this payment by the auto carrier has exceeded the plan's normal allowable
amount for this claim, no further payments of benefits are available from the plan on this claim. Therefore, we
decided that the Plan does not have to pay for the hospital emergency room services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on December
19, 2019.
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the charges
because a physician did not provide the procedure. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15
copayment for each visit with a specialist.
The medical records show that you received specialist services on December 19, 2019. Therefore, you are
responsible to pay the $15 copayment.
You have been asked to pay a $15 copayment for specialist services. Specialist services fall within the
physician/practitioner services, including doctor's office visits 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 specialist services provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on
January 9, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Plan pays $1,000
per year for visits and you have only received $80.00 (half of a routine visit). You also say that you would like
the Plan to pay for the $80.00 bill you received from the dentist. The Plan denied your request. The Plan says
you are responsible for all fees billed by the out-of-network provider in excess of the allowed amount.
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 amount and allowed amount for services received OON. Therefore, we decided that the Plan
does not have to pay for the periodic oral evaluation and prophylaxis provided on January 9, 2020 by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services (97016, 97032, 97112, 96372) and injections (J3490, J3420, J3415, J3411) provided in a chiropractic office on December 17, 2019.
You asked the Plan to pay for therapeutic services and injections. You say that these services should be covered. The Plan denied your request. The Plan says these services are not covered when provided in a chiropractic office.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan offers an additional benefit for routine chiropractic services provided by a licensed chiropractor. The records show that the services at issue are not manual manipulation of the spine or routine chiropractic services provided by a licensed chiropractor. Therefore, we decided that the Plan does not have to pay for therapeutic services (97016, 97032, 97112, 96372) and injections (J3490, J3420, J3415, J3411) provided in a chiropractic office on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the office visits, laboratory services and x-ray provided from August 27, 2019 through November 14, 2019.
You asked the Plan to waive the cost for the office visits, laboratory services and x-ray. You say that you are entitled to preventive care. You say that the visits are not being handled correctly. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $975. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Out-of-network services are not excluded from the deductible. Your contract with the Plan also says that after you pay your $975 deductible, you pay a $50 copayment for out-of-network primary care physician services and physician specialist services and a $15 copayment for x-rays from an in-network provider.
The item or service you asked the Plan to waive the cost for falls within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.
Date of Service
Service
Network Status
Standard Cost
Member Liability
August 27, 2019
Office Visit
Out-Of-Network
Deductible
$168.47
September 18, 2019
Office Visit
Out-Of-Network
Deductible
$50
October 8, 2019
Office Visit
Out-Of-Network
Deductible
$50
November 1, 2019
Laboratory Tests
Out-Of-Network
Deductible
$116.99
November 1, 2019
Office Visit
Out-Of-Network
Deductible
$111.38
November 6, 2019
Hip X-Ray
In-Network
$15
$15
November 14, 2019
Office Visit
In-Network
$50
$50
TOTAL:
$561.84
The Plan has followed Medicare rules by clearly disclosing in the contract that your $975 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network services were received. The records do not support that you received Medicare preventive services. Therefore, we decided that the Plan does not have to waive the cost for the office visits, laboratory services and x-ray provided from August 27, 2019 through November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does have a documented need for skilled therapy, including physical and occupational therapy, but there is no documented need for an intensive, complex interdisciplinary rehabilitation course. 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, first intraoral
periapical x-ray, and each additional intraoral periapical x-ray provided on November 25, 2019.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and intraoral periapical x-rays. You say
that your provider told you that the preventive services are not part of the $500 maximum, and the cleaning
would be paid independently. The Plan denied your request. The Plan says these services are covered benefits,
but you have exceeded the limits set in the subscriber agreement. The Plan says that your $500 benefit max was
met prior to the processing of this claim.
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 Plan offers a $500 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on July 26, 2019 and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, first intraoral periapical
x-ray, and each additional intraoral periapical x-ray provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services and a blood pressure monitor/blood pressure monitoring provided on September 5, 2019. 
 
You asked the Plan to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24 hours. 
 
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 A4670 is automatic bp monitor, dial. 
 
We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable.  Based on this information, we decided that Medicare rules for coverage of a blood pressure monitor/blood pressure monitoring during an ambulance transport. have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services and a blood pressure monitor/blood pressure monitoring provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) treatment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network TMS treatment. You say that TMS therapy is medically necessary and would allow you to have a better quality of life. The Plan denied your request. The Plan says they agree your condition makes TMS medically necessary, but that these services are available in-network.
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 transcranial magnetic stimulation (TMS) treatment to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you presented to the acute hospital with a right humerus fracture and a left femur fracture due to a fall. You underwent surgical repair of the femur fracture in the hospital. You required contact guard assistance with transfers and walking 5 steps with a hemiwalker. You required minimal to moderate assistance for activities of daily living except maximum assistance with bathing. You were medically stable. The documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you require physical therapy and occupational therapy, your 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 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head/brain, laboratory services, ECG tracing, ED visit, hospital observation service, and Enoxaparin Sodium injection provided from October 7, 2019 to October 8, 2019.
You asked the Plan to pay for the CT of the head/brain, laboratory services, ECG tracing, ED visit, hospital observation service, and Enoxaparin Sodium injection. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of the head/brain, laboratory services, ECG tracing, ED visit, hospital observation service, and Enoxaparin Sodium injection provided from October 7, 2019 to October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternative drugs can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Euflexxa. Our reviewer says that Euflexxa is not medically necessary in this case. Our physician reviewer found the enrollee did not trial the plan preferred drugs and the record does not show any reason they would be ineffective or unsafe for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on April 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on February 19, 2020.
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the Plan should pay this claim. The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis provided on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (CPT 99291) provided on November 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. The rules say that critical care is not a service that is paid on a "shift" basis or a "per day" basis. Critical care service is paid on a time-based service provided on an hourly or fraction of an hour basis. For this reason, the documentation provided by the physician must include the amount of time in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the medical documentation to show the total time spent delivering critical care to the enrollee. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (CPT 99291) provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) and prophylaxis (D1110) provided January 28, 2020.
You asked the Plan to pay for the dental services. You say that you were not informed that this medical provider was no longer in-network for 2020 and to find another in-network dentist. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
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 health plan contract says care rendered by a provider that is not a port of the supplemental dental network is not covered. 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 periodic oral exam (D0120) and prophylaxis (D1110) provided January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the skin surgery provided on January 30, 2020.
You asked the Plan to waive the deductible for the skin surgery. You say that you believe you should only be charged for one line of the three lines billed. You also say you should not be responsible for the service. 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. Your contract with the Plan says that there is a $290 deductible that applies towards in-network skin surgery. The skin surgery you asked the Plan to waive the deductible for falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 deductible that applies towards in-network skin surgeries. This cost sharing is a contractual obligation that had not been met at the time the skin surgery was received on January 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the skin surgery provided on January 30, 2020.