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

We decided that the Plan does not have to pay for the Comprehensive Cardiac Gene Panel provided on July 18, 2020.

You asked the Plan to pay for the Comprehensive Cardiac Gene Panel. You say that this was ordered by the treating physician and should be considered medically necessary. The Plan denied your request. The Plan says this is a screening test which is not covered by Medicare.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue evaluates for inherited cardiac diseases. However, the enrollee has no reported signs or symptoms of cardiac disease. Diagnoses include a family history of heart disease and genetic susceptibility of other disease. The only medical diagnoses are hypertension and diabetes which are risk factors for heart disease but not a sign or symptom. As such, this testing would be considered screening in nature and is not among those screening tests which Medicare covers. Therefore, we decided that the Plan does not have to pay for the Comprehensive Cardiac Gene Panel provided on July 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment (E0431 and E1390), provided on July 8, 2021.

You asked the Plan to pay for the oxygen equipment. You say that the item is medically necessary. The Plan denied your request. The Plan says the member resides in a skilled nursing facility and oxygen would not be covered in this setting.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that the oxygen equipment was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the oxygen equipment (E0431 and E1390), provided on July 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on December 24, 2019.

You asked the Plan to pay for therapeutic exercises. The Plan denied your request. The Plan says new documents were submitted for this appeal and consist of a progress note and physical therapy assistant visit note for various dates other than the billed date of service. Duplicates of records previously reviewed were also submitted.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care provided on August 20, 2021, through August 24, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copay each day one through six for inpatient hospital care. 

You have been asked to pay a $275 copay each day one through six for the inpatient care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient care provided on August 20, 2021, through August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) device (E0730), provided on September 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied your request. The Plan says you did not obtain this item through a network 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 the Transcutaneous Electrical Nerve Stimulation (TENS) device (E0730), provided on September 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Urine Wellness panel provided on April 1, 2021, billed with codes 88104, 88342, 88341, and two units of 88120.

You asked the Plan to pay for the Comprehensive Urine Wellness panel. You say that this was medically necessary. The Plan denied your request. The Plan says this type of test is not covered for screening for bladder cancer.

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 pay for the Comprehensive Urine Wellness panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the enrollee is a female with low back pain with possible E. coli infection. There was no other clinical information provided in the records. The limited records provided do not support the medical necessity of this testing. 

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 Comprehensive Urine Wellness panel have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Urine Wellness panel provided on April 1, 2021, billed with codes 88104, 88342, 88341, and two units of 88120.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services received from September 17, 2021 to September 18, 2021.

You asked the Plan to waive the copayment for the services. You say that you were in the emergency room for 7.5 hours before you were seen. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room care. 

You have been asked to pay a $90 copayment for the services. The services fall within the emergency room care 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 emergency room services received from September 17, 2021 to September 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cancer screening panel (81435, 81403, 81308, 81437) provided on December 11, 2020.

You asked the Plan to pay for a hereditary cancer screening panel. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that tests performed for screening hereditary cancer syndromes are not considered a Medicare benefit (statutorily excluded), and therefore will be denied as Medicare Excluded Tests. 

We looked at the file and Medicare rules. The testing at issue is excluded from Medicare coverage. Based on this information, we decided that Medicare rules for coverage of a hereditary cancer screening panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cancer screening panel (81435, 81403, 81308, 81437) provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 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 services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on July 14, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you would like the copayment to be changed. The Plan denied your request. The Plan says the proper copayment was 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 $90 copayment for each emergency room visit.

You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the Emergency Care 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 an emergency room visit provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three additional intraoral x-rays (D0230) provided on September 23, 2021.

You asked the Plan to pay for the intraoral x-rays. You say that you were told this was an in-network provider and you would be covered for this care. The Plan denied your request. The Plan says they have agreed to reprocess and pay for the first intraoral x-ray and the comprehensive oral exam, however the remaining intraoral x-rays exceed the frequency limitations of your dental benefit and remain denied.

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 can cover one intraoral x-ray per calendar year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral x-rays were provided in a frequency that exceeds what is covered under this benefit. The Plan paid for the first intraoral x-ray provided on the same date. Therefore, we decided that the Plan does not have to pay for the three additional intraoral x-rays (D0230) provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) and two resin-based composites (D2335 x2) provided on August 2, 2021, and August 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay more for the problem focused limited oral evaluation and resin-based composites. You say that you were told that the provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that OON providers are allowed to balance bill you for the difference between their billed amount and the Plan's paid 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 a 20% coinsurance of the covered plan allowance for restorations after the $100 annual deductible is met. You are also responsible for the difference between the billed amounts and allowed amounts because these services were received OON. The records show that there was no call history from the provider's office to the Plan. Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140) and two resin-based composites (D2335 x2) provided on August 2, 2021, and August 9, 2021 by an out-of-network (OON) provider.

Your complaint about being misinformed that the treating provider was in-network 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that SNF care remains medically necessary. The Plan denied your request. The Plan says that SNF care is no longer medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the criteria for the continuation of SNF care have been met. Our physician reviewer found the Plan is basing its denial on a therapy note from February 4, 2022. This note has not been provided for review. As such, the health plan has failed to provide documentation to support its denial.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 27, 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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an assisted living facility setting and should have been billed with POS code 13. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis provided on October 19, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON urinalysis. You say that this was medically necessary testing ordered by the treating physician. The Plan denied your request. The Plan says the ordering physician and the rendering lab are both OON with the Plan. No authorization was requested which is required for non-emergency services provided OON.

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 urinalysis provided on October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) provided on July 30, 2021.

You asked the Plan to waive the copayment for an MRI. You say that the claim was processed as an Out-of-Network provider, and you should not pay 42.3% of the bill. The Plan denied your request. The Plan says the claim was processed as an In-Network provider and the proper copayment was 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 $150 copayment for Advanced Imaging Services in a Outpatient Hospital.

You have been asked to pay a $150 copayment for an MRI. An MRI falls within the Outpatient hospital 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 a magnetic resonance imaging (MRI) provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injection services received on September 10, 2021.

You asked the Plan to waive the copayment for the services. You say that you cannot afford this. The Plan denied your request. The Plan says the copayment was applied appropriately.

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 $290 copayment for outpatient hospital services. 

You have been asked to pay a $290 copayment for the services. The services fall within the outpatient hospital 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 injection services received on September 10, 2021.
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 SNF care. You say that SNF care is medically necessary for your condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that based on the documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided 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 SNF care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation (D0140), periapical x-ray (D0220), and coronavirus fee (D1999) provided on October 23, 2021.

You asked the Plan to reimburse an additional amount for the dental services. You say that you should be reimbursed the full amount. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the limited oral evaluation and periapical x-ray are listed as covered, out of network dentists may bill you for any amount greater than what the Plan pays. Additionally, the coronavirus fee is not among those covered under this benefit, regardless of the dentist's network status. Therefore, we decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation (D0140), periapical x-ray (D0220), and coronavirus fee (D1999) provided on October 23, 2021.