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

We decided that the Plan does not have to pay for the screening services provided on May 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the screening services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 screening services provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a total hip replacement (27130) provided April 19, 2021.

You asked the Plan to waive the copayment for the total hip replacement. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $330 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $330 copayment for a total hip replacement. The record indicates that these services were performed in an outpatient setting. Hip replacements fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 total hip replacement (27130) provided April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shoulder brace (L3960) provided on August 4, 2021.  You asked the Plan to pay for a shoulder brace. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder brace (L3960) provided on August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Repatha Sureclick for the enrollee.  You asked the Plan to pre-approve the drug. You say that the enrollee has tried and failed Atorvastatin, Crestor, and Zetia. The Plan denied your request. The Plan says Repatha Sureclick is on the self-administered drug list and is excluded from coverage under Part B.  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 pre-approve Repatha Sureclick for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #19 and crowns (D2740) for tooth #'s 21 and 29.

You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says these crowns do not meet the criteria for 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. The Plan covers the crowns when the services are medically necessary and reasonable. 

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 crowns. Our reviewer says that the crowns are not medically reasonable and necessary. Our physician reviewer found given the poor condition of tooth #29, there is no necessity for a crown. Our reviewer found that tooth #21 does not have sufficient structure compromised such a crown would be necessary to add strength to the tooth, and Plan criteria for amount of missing structure and cusps has not been met. Our physician reviewer also found that the existing crown on tooth #19 appears to be functioning despite an open margin, and therefore would not require replacement at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #19 and crowns (D2740) for tooth #'s 21 and 29.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a laminectomy (63047, 64635), a coccygectomy (27080), and a fluoroscopy (76000) provided on March 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a laminectomy, a coccygectomy, and a fluoroscopy. You say that  The Plan denied your request. The Plan says the services performed by this non-participating provider were not authorized by the Plan. The Plan also says that the medical records provided do not reveal any medical urgent or emergent 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 a laminectomy (63047, 64635), a coccygectomy (27080), and a fluoroscopy (76000) provided on March 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 2, 2021 to July 1, 2021.

You asked the Plan to pay for home health services. You say that this claim was billed correctly per Medicare guidelines and should be processed for payment. The Plan denied your request. The Plan says the provider failed to submit the final bill within the 120 days are required for RAP claims.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, The RAP was received on August 27, 2021 and the 1/30th reduction would be to the 30th day period payment amount. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 2, 2021 to July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 21, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you understand the maximum exceeds this claim, but you feel that due to special circumstances of this claim, the teeth were replaced due to a seizure, and you had no front teeth. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.    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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 17, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 21, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 21, 2022.  You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that a continued SNF stay is not medically necessary.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 21, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 21, 2022.   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 12, 2021, to August 18, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in the hospital due to having the coronavirus and disagree with the charges. 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 $245 copayment for days 1-6 for inpatient hospital care.     You received inpatient hospital care from August 12, 2021, to August 18, 2021. The coronavirus waiver was no longer in effect at the time you received the services. Therefore, you are responsible to pay a $245 copayment for days 1-6 (August 12, 2021, to August 17, 2021). The total amount you owe is: $245 (copayment) x 6 (inpatient hospital care) = $1,470.   You have been asked to pay the total copayment amount of $1,470 for inpatient hospital care. Inpatient hospital care 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 inpatient hospital care provided from August 12, 2021, to August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the transurethral electrosurgical resection of the prostate (52601) provided on May 4, 2021.  You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the service provided.  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 your annual deductible is $1,000. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. Additionally, you must pay $250 per day after the deductible for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.  You have been asked to pay $390.12 which includes the amount of $140.12 as you had not fully met the deductible for this calendar year. Additionally, this includes the copayment of $250 for the outpatient surgery provided. 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 cost share for the transurethral electrosurgical resection of the prostate (52601) provided on May 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from April 5, 2021, to April 8, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be covered as outpatient. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $225 copayment per day for Inpatient hospital care.     You have been asked to pay a $225 copayment per day for three days of inpatient hospital care ($225 x 3 = $675). The Plan states that if these services were rendered as outpatient your bill would be well over $800. 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 inpatient hospital care provided from April 5, 2021, to April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and collection of blood sample (99204, 36415) provided on July 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit services. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 office visit and collection of blood sample (99204, 36415) provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical preparation for skin replacement surgery, skin substitute grafts (CPT) 15271) and repair procedures on the anus (CPT 46706).  You asked the Plan to pre-approve surgical preparation for skin replacement surgery, skin substitute grafts and repair procedures on the anus. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the requested services are experimental and unproven.  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 surgical preparation for skin replacement surgery, skin substitute grafts and repair procedures on the anus. Our reviewer says that the requested surgical preparation for skin replacement surgery, skin substitute grafts and repair procedures on the anus are not considered medically reasonable and necessary in this case.  Our physician reviewer found you have an anorectal fistula. You have undergone LIFT procedure twice and fistulotomy. Tisseel and Revita are injectable allograft material not Food and Drug Administration (FDA) approved for anorectal fistula use. Review of the available evidence did not reveal sufficient high quality supportive information to help justify this request. Therefore, the skin graft (injectable) will be considered not medically necessary at this time.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical preparation for skin replacement surgery, skin substitute grafts and repair procedures on the anus. have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical preparation for skin replacement surgery, skin substitute grafts (CPT) 15271) and repair procedures on the anus (CPT 46706).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare states non-thermal modalities for facet joint denervation using low-grade thermal energy (less than 80 degrees Celsius) is considered not reasonable and 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare states non-thermal modalities for facet joint denervation using low-grade thermal energy (less than 80 degrees Celsius) is considered not reasonable or necessary and will be denied. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 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 procedure codes 80157, 80177, 80201, 80159, and 80173 are 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.  We find that CPT codes 80157, 80177, 80201, 80159, and 80173 are not supported in the medical record. Specifically, the records show that urine specimens were collected and not blood specimens. 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 laboratory services rendered on March 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 15, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel that you should not be responsible for the copayment since you were very sick and could not breathe. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way ground ambulance trip.   You have been asked to pay a $250 copayment for the ambulance transportation. Ambulance transportation falls within the Ambulance 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 ambulance transportation provided on August 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (unattended) (G0283) mechanical traction (97012) provided May 5, 2021.

You asked the Plan to pay for the chiropractic service. You say that the services were billed with the GA modifier and should not deny as CO. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electrical stimulation (unattended) (G0283) mechanical traction (97012) provided May 5, 2021.