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

We decided that the Plan does not have to waive the copayment for the MRI provided on February 4, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you were not told you would have a copayment and you cannot afford it. The Plan denied your request. The Plan says the enrollee was charged this copayment 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 $150 copayment for Outpatient Diagnostic Tests. 

The enrollee has been asked to pay a $150 copayment for the MRI. The MRI falls within the Outpatient Diagnostic Tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided January 18, 2021.

You asked the Plan to pay for the comprehensive oral exam and the complete series of x-rays. You say that you would like coverage provided in consideration of personal and financial stresses due to the pandemic. The Plan denied your request. The Plan says the frequency limitation for these services has been exceeded and therefore they are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the comprehensive oral exam once every three years and complete series x-rays once every five years. 

We looked at the file, and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam and panoramic x-rays were previously covered on February 4, 2019. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam and the complete series of x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery provided to you by an out-of-network provider on October 3, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 services 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 cataract surgery provided to you by an out-of-network provider on October 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered January 6, 2021 to January 18, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with TOB code 032x. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required TOB code 032x. 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 home health services rendered January 6, 2021 to January 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency transport ambulance service and ground mileage provided on December 1, 2019.
You asked the Plan to pay for the emergency transport ambulance service and ground mileage. You say that this claim was filed timely. The Plan denied your request. The Plan says this claim was not received until January 1, 2021, which is past the allowed 12 month time frame.
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 emergency transport ambulance service and ground mileage was not filed until January 6, 2021. 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 the emergency transport ambulance service and ground mileage provided on December 1, 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 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 was admitted for bilateral knee replacement
surgery. Medical conditions 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. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are stable. You do not have complex nursing or rehabilitation needs.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.

Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from an intensive rehabilitation therapy program provided 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on February 3, 2021.
You asked the Plan to pay for the office visit. You say that the doctor's office representative noted it was ok to see the doctor. You say that you would never had gone if you were told the doctor was not in-network. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 office visit provided by an out-of-network provider on February 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on July 28, 2020, and December 28, 2020.

You asked the Plan to waive the copay for the services provided. You say that if you stayed overnight, your cost would have been limited to $430. The Plan denied your request. The Plan says the claims processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance in an outpatient hospital for outpatient surgery.

You have been asked to pay a 20% coinsurance on each date of service, for each knee surgery. The services fall within the outpatient surgery 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 copay for the outpatient surgery services provided on July 28, 2020, and December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on September 25, 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 99285 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 99152 is Moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer for moderate sedation services. 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 moderate sedation services rendered on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, problem focused limited re-evaluation, and removal of residual tooth roots provided on December 16, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, problem focused limited re-evaluation, and removal of residual tooth roots. You say that you did not see in your contract that it says you need to be seen by a participating provider. The Plan denied your request. The Plan says the treating provider opted out of the Medicare Program effective September 7, 2017, to September 7, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.
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 rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, problem focused limited re-evaluation, and removal of residual tooth roots provided on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not taking insulin. There is no indication of why a glucometer is not sufficient for your needs. The criteria for this monitor is not met. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for progressive lenses (V2781), frames (V2020), and anti-reflective coating (V2750) received on October 1, 2020.
You asked the Plan to pay an additional amount for progressive lenses, frames, and anti-reflective coating. You say that you would like the Plan to pay an additional amount toward the purchase. The Plan denied your request. The Plan says the benefits were applied correctly. The benefit allowance of $200 was applied to the purchase leaving a member responsibility of $529.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $200 allowance per year. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of progressive lens, frames, and anti-reflective coating have not been met. Specifically, the record shows that you had exhausted your eye wear benefit maximum of $200 and are therefore, responsible for paying the remainder of $529. Therefore, we decided that the Plan does not have to pay an additional amount for progressive lenses (V2781), frames (V2020), and anti-reflective coating (V2750) received on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services 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 services provided by an out-of-network provider on October 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services were not urgent or emergent in nature.
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 lab work provided on December 7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 25, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the date on the claim does not match the records submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The date of service of the test/service must be the date the specimen was collected.
We find that CPT code G0483 is not supported in the record. Specifically, the record indicates that the specimen was collected on August 14, 2020, but the claim was billed with August 25, 2020 as the date of service. The record does not match the claims date of service. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. 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 he 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 stroke in 2016 with
residual left sided weakness, atrial fibrillation, seizure disorder and diabetes and is living at home with
complaints of increasing weakness. Medical conditions 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. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
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.