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

We decided that the Plan does not have to waive the coinsurance for an electrophysiology evaluation
performed from February 24, 2021, to February 26, 2021.
You asked the Plan to waive the coinsurance for the electrophysiology evaluation. You say that you feel that
the charges are excessive and that you did not stay in the hospital for 3 nights. The Plan denied your request.
The Plan says the correct coinsurance 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 20%
coinsurance for diagnostic procedures and tests performed in an outpatient hospital.
You have been asked to pay $4199.48, which is 20% of the allowed amount for the electrophysiology
evaluation ($20,997.41 allowed amount x 20% coinsurance = $4199.48). Please note that the coinsurance
applies only to the procedure, not the number of days/nights spent at the hospital. The electrophysiology
evaluation falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for an electrophysiology evaluation performed from February
24, 2021, to February 26, 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 reasonable and necessary for the enrollee's 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 the beneficiary is an 86-year-old female with a fall and coronavirus infection. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for 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 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy (PT) visits.  You asked the Plan to pre-approve 12 additional outpatient PT visits. You say that the requested visits are medically necessary. The Plan denied your request. The Plan says the additional visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 12 additional outpatient PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation does not support that the requested therapy generally accepted as specific and effective therapy for the enrollee's condition. The reviewer found that the provided documentation indicates that the enrollee has been educated on a home exercise program (HEP) and therefore can perform the exercises on their own. The reviewer also found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the requested additional physical therapy visits are not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional outpatient PT visits have not been met. Specifically, the file indicates that the provided documentation does not support that the requested therapy generally accepted as specific and effective therapy for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary assessment for cardiac conditions provided to the enrollee on April 6, 2021.    You asked the Plan to pay for the screening services. You say that this service was denied as experimental in error. The Plan denied your request. The Plan says Medicare does not cover screening tests, examinations, and therapies for which the enrollee has no symptoms or documented conditions, unless those screening services are specifically identified on a Medicare covered list.  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, the screening services, 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 hereditary assessment for cardiac conditions provided to the enrollee on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an unspecified preventative procedure (D1999) provided by a participating provider on August 9, 2021.  

You asked the Plan to pay for a limited oral evaluation and an unspecified preventative procedure. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0140 has already been exhausted. The Plan says that D1999 is not a covered benefit.  

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 a limited oral evaluation once per 36 months. An unspecified preventative procedure is not a covered benefit.  

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been exhausted. Evidence was provided to show that D0140 was provided on February 10, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an unspecified preventative procedure (D1999) provided by a participating provider on August 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the imaging of retina services (92134) provided on May 5, 2020.  You asked the Plan to pay for the imaging of retina services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says that this claim must be processed through the skilled nursing facility (SNF) the enrollee was in at the time services were rendered.  The Plan must follow Medicare rules. Medicare rules say that physician's professional services and services of certain nonphysician providers are excluded from Part A Prospective Payment Systems (PPS) payment and the requirement for consolidated billing.  We looked at the file and Medicare rules. The claim at issue in this appeal was for an ophthalmology service, a physician service, which means this is not included in the PPS. Based on this information, we decided that Medicare rules for coverage of the imaging of retina services have been met. Therefore, we decided that the Plan has to pay for the imaging of retina services (92134) provided on May 5, 2020.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core build up (D2950), and crown (D2740) for tooth # 14 provided from August 10, 2021, to August 26, 2021.  You asked the Plan to pay for the dental services. You say that you selected the provider in this case from a list that was given to you by a plan representative with participating dentists in your area. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that crown is not listed as a covered service either.  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 core build up and crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), and crown (D2740) for tooth # 14 provided from August 10, 2021, to August 26, 2021.
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. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care.  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 physician reviewer found that the enrollee was admitted to the acute care hospital with acute hypoxic respiratory failure and coronavirus pneumonia. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.   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: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pay for the segmental gradient pressure pneumatic appliance (CPT code E0673-NU-RT and E0673-NU-LT) provided on July 21, 2021.  You asked the Plan to pay for the DME. You say that you had shoulder surgery and the services were medically necessary. The Plan denied your request. The Plan says that CPT codes E0673-NU-RT and E0673-NU-LT denied as it was billed with inappropriate place of service (24-Ambulatory surgery center).  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan's denial is not substantiated. They reprocessed CPT code E0675 even though the DME was billed with the same place of service as E0673. Therefore, we decided that the Plan has to pay for the segmental gradient pressure pneumatic appliance (CPT code E0673-NU-RT and E0673-NU-LT) provided on July 21, 2021.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve myocardial imaging testing.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the documentation does not show a heart muscle evaluation is needed.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.     The file shows that a radionuclide imaging (RNI) was requested. 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 requested services. Our physician reviewer found that the enrollee had a previous radionuclide stress test in July 2019, thought to be likely negative but a confounding diaphragm artifact was reported. It would be appropriate to carry out either a regular treadmill exercise test, exercise-pharmacologic stress echocardiogram, or a radionuclide stress test. The Plan indicates a preference to perform stress echocardiography before considering a radionuclide test. This alternative is reasonable and would be considered equivalent to radionuclide stress testing. Moreover, the enrollee's radionuclide test, performed less than 3 years ago, was to some extent limited by diaphragm artifact. A stress echocardiogram would avoid this potential limitation. As a result, at this time radionuclide testing would not be considered medically necessary in this enrollee's clinical management.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial imaging testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99336) provided on September 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that this was medically necessary for the patient to receive the treatment by the provider, and you did not know that the facility failed to get preauthorization for this patient, so you treated him anyway. The Plan denied your request. The Plan says the services were rendered by non-participating providers. The Plan also says that they 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 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 domiciliary or rest home visit (99336) provided on September 14, 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 targeted genomic sequence analysis panel (0239U) rendered by the out-of-network (OON) provider on March 17, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0239U) rendered by the out-of-network (OON) provider on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the brief behavioral assessment (96127) provided on July 14, 2021.  You asked the Plan to waive the copayment for the brief behavioral assessment. 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 $30 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.    You have been asked to pay a $4.60 copayment for a brief behavioral assessment, which is less than the $A30 stated in the Plan's contract. Behavioral assessment falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 brief behavioral assessment (96127) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retainer crowns (D6750 x 2) and pontic (D6240) provided on September 21, 2021.  You asked the Plan to pay for the fixed bridge. You say that the service should be covered. The Plan denied your request. The Plan says fixed bridge is not a covered service.  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 fixed bridge is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6750 x 2) and pontic (D6240) provided on September 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits.  You asked the Plan to pre-approve 12 PT visits. You say that you would not have gone for therapy if your doctor had not felt that you needed it. The Plan denied your request. The Plan says the additional physical therapy visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 12 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation does not support that the requested therapy generally accepted as specific and effective therapy for the enrollee's condition. The reviewer found that the provided documentation indicates that the enrollee has been educated on a home exercise program and therefore can perform the exercises on their own. The reviewer also found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Therefore, the reviewer found that the requested additional physical therapy visits are not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 PT visits have not been met. Specifically, the file indicates that the provided documentation does not support that the requested therapy generally accepted as specific and effective therapy for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 12 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) machine provided on September 20, 2021.  You asked the Plan to waive the coinsurance for the CPAP machine. You say that the humidifier is not removable and you should not have a copayment for that. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each durable medical equipment (DME) item and related supplies, including CPAP machines.   You have been asked to pay $54.80, which is 20% of the allowed amount for the CPAP machine ($274 allowed amount x 20% coinsurance = $54.80). The CPAP machine falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) machine provided on September 20, 2021.