Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) (D7250) provided August 25, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the removal of residual tooth roots. You say that the dental office is in your provider's guide and you feel the service should be covered. The Plan denied your request. The Plan says this service is not covered when provided out-of-network.  

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 removal of residual tooth roots when the services are provided in-network.  

We looked at file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the removal of residual tooth roots have not been met. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) (D7250) provided August 25, 2021 by an out-of-network (OON) provider.   

Your complaint about potentially being provided incomplete or incorrect information in a Plan document 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and four periodontal scalings and root planings (D4341 x4) provided on June 22, 2021.  

You asked the Plan to pay for the oral hygiene instructions and scalings and planings. You say that you talked to the dental receptionist after the scaling and planing and were told that an untrained person in billing advised that the cost would be $305 but it was really $305 per quadrant, or $1,200 total. You also say that you would have never consented to that amount if you had known. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and four periodontal scalings and root planings (D4341 x4) provided on June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (36556-51 and 92950-51) provided on February 11, 2021.  You asked the Plan to pay for codes 36556-51 and 92950-51. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, modifier 51 is inappropriate to report. The Multiple Surgery indicator for codes 36556 and 92950 is 0. No payment adjustment rules for multiple procedures apply. Therefore, we decided that the Plan does not have to pay for the services (36556-51 and 92950-51) provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided on May 4, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician determined that this testing was medically necessary. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network 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 genetic testing provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for Skilled Nursing Facility (SNF) services provided on November 10, 2020, through November 17, 2020 and billed with the Patient Driven Payment Model Score JEUF1 x 7 days.  You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation provided does not support all of the Section GG payment items as coded.  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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has not stated what information on the assessment is not valid. There is no evidence as to why these services are not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for Skilled Nursing Facility (SNF) services provided on November 10, 2020, through November 17, 2020 and billed with the Patient Driven Payment Model Score JEUF1 x 7 days.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office services (CPT code 99214) provided to the enrollee on August 13, 2021, by out-of-network providers.  You asked the Plan to pay for the out-of-network office services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 the office services (CPT code 99214) provided to the enrollee on August 13, 2021, by out-of-network providers.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services 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 this is denied due to a lack of medical necessity.  

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 the services. 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy but the quantity of this therapy and details of the outcome are not documented. The most recent progress notes do not reveal objective functional deficits that would require 32 more formal therapy sessions. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program.  

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 physical therapy services for the enrollee.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to waive the copayment for the emergency room services provided from  August 18, 2021, through August 20, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the services provided.  

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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, you stated that you were subsequently admitted into the hospital for treatment following your emergency room visit. The Plan contract states that you do not have to pay the emergency room cost share if you are admitted to the hospital within 24 hours for the same condition. The Plan did not notify or forward medical records to our organization regarding this inpatient hospital admission. Therefore, we decided that the Plan has to waive the copayment for the emergency room services provided from August 18, 2021, through August 20, 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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on May 3, 2021.  

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (CPT code 92136) provided on June 30, 2021.  

You asked the Plan to waive the copayment for the service. You say that the services should be covered. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).   

Review of the file shows that you received ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (CPT code 92136) on June 30, 2021. Since the allowable for the service is less than the copayment, you are being asked to pay the lesser amount of $30.09. This service is not included in the global payment for the first surgery and, was in preparation for a second eye surgery. Medical records show you had post-op visit on this day also. 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 ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (CPT code 92136) provided on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage (A0425) provided June 5, 2021.  You asked the Plan to waive the copayment for the ambulance service. You say that the service was medically necessary and should be covered. 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 $250 copayment for each one-way Medicare covered ambulance transport.  You have been asked to pay $250 copayment for the ambulance service. This service 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 the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage (A0425) provided June 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on May 28, 2021.  

You asked the Plan to waive the copayment for CT scan. You say that you cannot afford this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  

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 $110 copayment for in-network CT scan.   

You have been asked to pay $110 copayment for CT scan. CT scan 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 a computed tomography (CT) scan provided on May 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health physical, speech and occupational therapy provided from January 28, 2021, through March 25, 2021.  

You asked the Plan to pay for home health physical, speech and occupational therapy. The Plan denied your request. The Plan says these services are not medically necessary.  

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  

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 home health physical, speech and occupational therapy. Our reviewer says that home health physical, speech and occupational therapy are not medically necessary. Our physician reviewer found that the documentation does not support that the enrollee required skilled rehabilitation services to provide treatment that was medically necessary. The enrollee did not require skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She was independent with locomotion and mobility and only required minimal assistance with bathing. The documentation does not support that she required the extensive home health therapy services. The requested home health services are not medically 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 home health physical, speech and occupational therapy have not been met. Therefore, we decided that the Plan does not have to pay for home health physical, speech and occupational therapy provided from January 28, 2021, through March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crowns - porcelain/ceramic substrate (D2740) provided May 6, 2021.  

You asked the Plan to pay for the crowns. You say that you did not know that the frequency limit applied to both crowns and fillings combined. The Plan denied your request. The Plan says you have exceeded the frequency limit for this type of 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. The Plan restorative services twice per year.  

We looked at the file and Medicare rules. The Plan provided documentation showing that a crown was covered on January 28, 2021, and a filling was covered on February 17, 2021. Crowns and fillings are both considered restorative services. Based on this information, we decided that the Plan's frequency limit for coverage of the crowns has been exceeded. Therefore, we decided that the Plan does not have to pay for the crowns - porcelain/ceramic substrate (D2740) provided May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the stroke recovery system (E0849), provided on July 6, 2021.  

You asked the Plan to waive the coinsurance for the stroke recovery system. You say that the item 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 20% coinsurance for durable medical equipment (DME) and related supplies.          

You have been asked to pay a 20% coinsurance for the stroke recovery system. This item 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 the stroke recovery system (E0849), provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health services and chiropractic services provided on February 3, 2021, to July 7, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the medical services. You say that you would like to be reimbursed for the services you received. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by OON providers.  

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 outpatient mental health services and chiropractic services provided on February 3, 2021, to July 7, 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 pulmonary function testing (CPT code(s): 94640, 94618, 94729, 94726) provided on September 3, 2021, by an out-of-network provider.  

You asked the Plan to pay for the out-of-network services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 the pulmonary function testing (CPT code(s): 94640, 94618, 94729, 94726) provided on September 3, 2021, by an out-of-network provider.