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

We decided that the Plan does not have to waive the copayments for the screening mammogram, the diagnostic
mammogram, and the ultrasound provided from October 30, 2020, to November 13, 2020.

You asked the Plan to waive the copayments for the screening mammogram, the diagnostic mammogram, and
the ultrasound. You say that you were advised to have another mammogram and ultrasound done to make sure
nothing was wrong. You would have never had another mammogram if there was nothing suspect. The Plan
denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0
copayment for covered screening mammograms, an $80 copayment for a diagnostic mammography at an innetwork
outpatient hospital, and a $110 copayment for basic radiological services at an in-network outpatient
hospital.

You have been asked to pay total copayment of $110 for the screening mammogram, the diagnostic
mammogram, and the ultrasound. The screening mammogram falls within the "Breast cancer screening
(mammograms)" benefit category. The diagnostic mammogram and the ultrasound fall within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The record shows the breast cancer
screening benefit was exhausted on October 30, 2020. See chart below.

Date of Service Service Allowed Amount Copayment Member Liability
October 30, 2020     Screening mammogram     $114.62      $0      $0
November 13, 2020    Diagnosticmammogram    $86.55      $80     $80
November 13, 2020     Ultrasound                       $78.01     $110    $30
Total                                                                                          $110

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 copayments for the screening mammogram, the diagnostic mammogram,
and the ultrasound provided from October 30, 2020, to November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no orthopedic evaluation is included in the records to evaluate the need for surgical intervention.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on November 10, 2020.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the diagnostic radiology services. 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 diagnostic radiology services provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), annual wellness visit (G0438), evaluation (99396) and urinalysis (81003) provided on August 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit (99214), annual wellness visit (G0438), evaluation (99396) and urinalysis (81003) provided on August 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided September 12, 2020.

You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that these items were medically necessary. The Plan denied your request. The Plan says it appears that patient did not receive video or telephonic visit by the ordering physician.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are 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 a knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and suspension sleeve (L2397) provided September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral for a CT scan of the abdomen, pelvis and chest and blood work.

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 is no evidence that the services cannot be done at the community level.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found CT scans are not urgent and can be done in community. 

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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level referral for a CT scan of the abdomen, pelvis and chest and blood work.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-position patient support system with integrated lift (E0636).

You asked the Plan to pre-approve the lift. You say that the enrollee requires the device for after a procedure. The Plan denied your request. The Plan says the Medicare criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that the enrollee must require supine positioning for transfers to qualify for this device. This enrollee does not. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a multi-position patient support system with integrated lift (E0636).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on October 5, 2020 by an out of network provider.

You asked the Plan to pay for Subsequent nursing facility care (99309). You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 the nursing facility care provided on October 5, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service (99358) provided on August 31, 2020, through September 2, 2020.

You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support that the time spent reviewing records was over 15 minutes.

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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour. 

We asked our coder 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 prolonged evaluation and management service. Our reviewer says that CPT code 99358 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records document that on August 31, 2020, September 1, 2020 and September 2, 2020 that less than 15 minutes per date of service was spent providing this service. The CPT Guidelines state that 99358 prolonged services that are less than 15 minutes should not be reported, therefore this service is not eligible for reimbursement consideration. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service (99358) provided on August 31, 2020, through September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from October 24, 2020, to October 29, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you believe these services were medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from October 24, 2020, to October 29, 2020.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, preventive procedure, and resin-based composite provided on September 1, 2020, and September 2, 2020 by you, an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, preventive procedure, and resin-based composite. You say that you were given misinformation, and were told that you were in-network with the enrollee's plan. The Plan denied your request. The Plan says there is no coverage for services rendered by an OON provider. The Plan also says that during your call with them, your office indicated that you were in-network, and no misinformation was provided to you by the Plan.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, preventive procedure, and resin-based composite provided on September 1, 2020, and September 2, 2020 by you, an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT code 99308) provided to the enrollee.

You asked the Plan to pay for the services. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of this claim. You state you depend on the facility for timely notification of the enrollee's health insurance coverage and are asking for an exception in this case. The Plan denied your request. The Plan says the claim was not filed timely.

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 the services was not filed until September 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (CPT code 99308) provided to the enrollee.
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 admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at an alternate 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met at a lower level of care.

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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely
and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex
wound care needs, or other skilled nursing needs. Your functional level does not require skilled therapy
services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and
effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services
are not required on a "daily basis" or as a practical matter on an inpatient basis, in a skilled nursing facility
setting.

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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Continuous Glucose Monitor (CGM).

You asked the Plan to preapprove the CGM. You say that you require the device to monitor your blood sugar. The Plan denied your request. The Plan says the service was denied due to not meeting medical necessity criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes mellitus. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on December 10, 2020.

You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the surgical pathology services. 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 surgical pathology services provided on
December 10, 2020.
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 reconsideration because you require physical therapy and are unable to be cared for at home. The Plan denied your request. The Plan says the records do not indicate that you need or are able to tolerate an 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges because you did not have a therapy evaluation. 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 $40 copayment for outpatient rehabilitation services.

You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 outpatient rehabilitation services.