Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 7, 2019, by an out-of-network
(OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.
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 physician services provided on May 7, 2019, by an
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires a higher level of care. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have 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 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. Our physician reviewer also found that the enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy can be tolerated or is required on an intensive level in an IRF. 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 the acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary. The
Plan denied your request. The Plan says the medical records do not provide evidence that the prescribing
physician ever saw the member.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer
says that the requested orthosis is not medically necessary and reasonable. Our physician reviewer found an
appropriate history and a physical examination of the back would reasonably be required to adequately assess
whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support
that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of an appropriate evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D 25 hydroxy coded 82306 and the Cyanocobalamin (Vitamin B-12) testing coded 82607 provided on September 10, 2200.
You asked the Plan to pay for the Vitamin D 25 hydroxy and the Cyanocobalamin (Vitamin B-12) testing. 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. We find that CPT code 82306 and 82607 is not supported in the medical record. Specifically, the documentation submitted to the plan does not include medical records. The documentation submitted does not support medical necessity of the services rendered. Based on this information, we decided that Medicare rules for coverage of the Vitamin D 25 hydroxy and the Cyanocobalamin (Vitamin B-12) testing have not been met. Therefore, we decided that the Plan does not have to pay for the Vitamin D 25 hydroxy coded 82306 and the Cyanocobalamin (Vitamin B-12) testing coded 82607 provided on September 10, 2200.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the scaling and root planing for 4 or more teeth per quadrant (D4341), the scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 3), gingival irrigation (D4291 x 4), and periodontal maintenance (D4910 x 2).

You asked the Plan to pay for the dental services. You say that you feel the Evidence of Coverage is misleading. You say that you were under the impression that you had a $2,000 allowance for dental services. You say that a plan representative confirmed this during a phone call. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan says that scaling and root planing are not listed as covered services. The Plan says gingival irrigation is not listed as a covered service. The Plan says periodontal maintenance is not listed as a covered service either. The Plan says that you did not purchase the optional supplemental dental 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, the services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the scaling and root planing for 4 or more teeth per quadrant (D4341), the scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 3), gingival irrigation (D4291 x 4), and periodontal maintenance (D4910 x 2).

Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and skin biopsy provided at a dermatologist's office on June 4, 2020.
You asked the Plan to waive the copayment for the dermatology services. You say that you do not believe this copayment should be charged because this should be treated as an outpatient procedure. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for services in a specialist's office. The enrollee has been asked to pay a $30 copayment for the dermatology services. The dermatology services fall within the services in a specialist's office benefit category 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 and skin biopsy provided at a dermatologist's office on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 8, 2020, to November 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member did not provide insurance information. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available 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 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 an office visit provided on October 8, 2020, to November 19, 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 anesthesia services (99231).

You asked the Plan to pay for anesthesia services. You say that the service was medically necessary. The Plan denied your request. The Plan says payment for this service was included in the payment for the base service.

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 CPT code 99231 is not supported in the medical record. Specifically, per the NCCI Policy Manual, routine postoperative evaluation by the anesthesiologist is included in the base anesthesia service. CPT code 00400 was already paid for the base service. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99231).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of congestive heart failure, hypertension, dementia and is living in an assisted living facility. He is having weakness and falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 10, 2020.
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 billed are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the file shows that the enrollee had cardiovascular risk assessment testing. All cardiovascular risk assessment panels, except the basic lipid panel for symptomatic enrollees with suspected or documented cardiovascular disease is not covered. This means that the laboratory testing at issue in this appeal 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 provided on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 29, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that the doctor recommended having another colonoscopy in 6 months. You say that polyps were not removed but you were charged another copayment. The Plan denied your request. The Plan says the copayment 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 $225 for each Medicare-covered, in-network, outpatient hospital facility visit. You have been asked to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show a diagnostic colonoscopy was performed. 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 colonoscopy provided on December 29, 2020.
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 services could be provided in another setting.
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 there is no documentation provided necessitating admission to a LTACH. 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 at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care supplies provided by a participating provider.

You asked the Plan to waive the coinsurance for wound care supplies. You say that you feel like these charges should not be sent to you. The Plan denied your request. The Plan says the correct coinsurance has been applied.

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 durable medical equipment/in-network.

You have been asked to pay a 20% coinsurance of the allowed amount for wound care supplies. The total allowed amount is $45.15. The total amount you are being asked to pay is $9.03 ($45.15 x 20% = $9.03). Since wound care supplies were provided, the correct coinsurance has been applied. Wound care supplies fall within the durable medical equipment/in-network 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 wound care supplies provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Next Generation Sequencing (NGS) services provided on September 24, 2020.
You asked the Plan to pay for the NGS services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says prior authorization was not obtained.
The Plan must follow Medicare rules. Medicare rules say that results provided to the treating physician for management of the enrollee using a report template to specify treatment options. We looked at the file and Medicare rules. Review of the file shows that there is no evidence that the enrollee's provider requested or even knew that this testing was going to be performed. Based on this information, we decided that Medicare rules for coverage of the NGS services have not been met. Therefore, we decided that the Plan does not have to pay for the Next Generation Sequencing (NGS) services provided on September 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 30, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 19, 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 procedure code G0483 is not supported.
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 G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 19, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on November 16, 2020 at a Veterans Affairs facility.
You asked the Plan to pay for the emergency department visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says services are not covered unless the enrollee is a non-veteran, and the services are urgent/emergent.
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 Veterans Affairs facilities only in cases involving non-veterans with urgent/emergent services. The record shows the enrollee is a veteran and the services took place a Veterans Affairs facility. 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 emergency department visit provided on November 16, 2020 at a Veterans Affairs facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture adjustment (D5422).

You asked the Plan to pay for the mandibular partial denture adjustment. You say that you would like to appeal this service. The Plan denied your request. The Plan says the maximum limitation allowed for adjustments for mandibular dentures/partials had been met.

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, mandibular partial denture adjustment (D5422) is limited to 1 of codes D5410 to D5422 once per arch every 12 months. The record shows that you received a mandibular partial denture adjustment (D5422) and your mandibular partial denture adjustment (D5422) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture adjustment (D5422).