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

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on 
April 29, 2021. 
 
You asked the Plan to reimburse you for the limited oral evaluation. You say that the provider's office advised 
they accepted your insurance. You say that they advised you needed to pay out of pocket and your plan would 
reimburse you. You also say that you should be reimbursed for these services. The Plan denied your request. 
The Plan says limited oral evaluation is not listed as 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 limited oral evaluation is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the limited oral evaluation (D0140) provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for stoke and coronavirus (COVID-19). Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on May 28, 
2020. 
 
You asked the Plan to waive the copayment for the office visit (99202). You say that you did not go to this 
provider and the claim is not for you. The Plan denied your request. The Plan says you were charged this 
copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Physician Services, specialist office visit. 

You have been asked to pay a $35 copayment for the office visit (99202). The podiatry office visit (99202) 
falls within the Physician Services, specialist office visit benefit category. The provider has confirmed you had 
the office visit for bilateral foot care. 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 podiatry services 
provided on May 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the computed tomography angiography 
(CTA) you had on May 11, 2021. 
 
You asked the Plan to waive the coinsurance for the CTA. You say that you already paid $20.14 to the doctor 
for this service and now you're getting a bill from the hospital. The Plan denied your request. The Plan says you 
were charged this coinsurance correctly. The CTA you had has two parts: the hospital physically performed the 
test, and the doctor read the results of the test. Both components of the CTA make up the total cost. 
 
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 20% 
coinsurance for diagnostic radiology services. You have been asked to pay 20% coinsurance for the CTA. Diagnostic radiology services such as CTAs are 
comprised of two parts: the "technical" component (which is the physical performing of the test), and the 
"professional" component (which is the doctor's reading and interpretation of the test). The total cost of the 
CTA is the cost of the technical component and the professional component combined. So far, you have only 
paid the coinsurance to the doctor for the professional component. The coinsurance also applies to the technical 
component of the test that was performed by the hospital. 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 computed tomography angiography (CTA) you had on May 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428, A0425) provided on April 13, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you should not be responsible for the charges. 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 $275 copayment for ambulance services. 

You have been asked to pay a $275 copayment for non-emergency ambulance transportation. The services at issue fall 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 non-emergency ambulance transportation (A0428, A0425) provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid due to these services being medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these 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 lab work provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.

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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with
neurogenic claudication. The record indicates that imaging has not demonstrated moderate spinal stenosis at the
the levels requested for treatment. The record does not indicate a surgical opinion that the enrollee is not
indicated for operative treatment at more than two levels. The elements of the coverage criteria are not
satisfied.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve glass lenses.
You asked the Plan to pre-approve glass lenses. You say that you have allergies and cannot use plastic lenses. The Plan denied your request. The Plan says that this is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a vision 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 pre-approve glass lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation
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 there has been no adequate trial of psychotherapy for depression.

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 the enrollee has tried several different agents but has not undergone an adequate trial of psychotherapy or
electroconvulsive therapy.

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 therapeutic repetitive transcranial magnetic stimulation for the enrollee.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve Cefepime. We decided that the Plan does not have to pre-approve Famotidine and home infusion therapy.
You asked the Plan to pre-approve Cefepime. You say that this drug is medically reasonable and necessary. The Plan says that the criteria for coverage have not been met.
We decided that the Plan has to pre-approve Cefepime.
The Plan follows Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.
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 Cefepime. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found the review indicates that the enrollee had cellulitis of the left foot and required intravenous (IV) antibiotic therapy. She was treated with IV Cefepime 2 gm every 12 hours. Cefepime is used for the treatment of uncomplicated skin and skin structure infections. The review indicates that the documentation supports that Cefepime is medically reasonable and necessary for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cefepime have been met. Therefore, we decided that the Plan has to pre-approve Cefepime.
We also decided that the Plan does not have to pre-approve Famotidine and home infusion therapy.
The Plan follows Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purpose. We looked at the file, and Medicare rules. In this case, these services have a status indicator of "I" under the Physician Fee Schedule which indicates that payment will not be made by Medicare for these services. Based on this information, we decided that Medicare rules for coverage of Famotidine and home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Famotidine and home infusion therapy.
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 emergency medicine services as billed with code 99291 
provided February 2, 2021. 
 
You asked the Plan to pay for the medical services billed. You say that you would like this claim reprocessed 
for medical necessity. The Plan denied your request. The Plan says the records do not support the services as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes 
 
We asked our coder 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 medical services billed. Our reviewer says that the 
medical records do not support the services as billed. Our reviewer found the documentation does not include 
the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code 
cannot be verified. It is noted that multiple attempts were made to contact the provider for additional
information. The medical records did not support the billed CPT code 99291. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the emergency medicine services as billed with code 99291 provided February 2, 
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from April 1, 2021 and April 15, 2021.
You asked the Plan to waive the copayment for these services. You say that you feel you do not owe the copayment. 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 $0 copayment for days 1-20 and a $184 copayment per day for days 21-100 for in-network Medicare-covered skilled nursing facility stays. Review of the file shows that you received SNF services from April 1, 2021 to April 15, 2021. You were initially admitted to the SNF on March 10, 2021. The services from April 1, 2021 to April 15, 2021 made up days 23-36 of your 100-day benefit period. You have been asked to pay a $184 copayment per day for these services, for a total of $2,576. These services fall within the in-network Medicare-covered skilled nursing facility stays 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 skilled nursing facility (SNF) services rendered from April 1, 2021 and April 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need therapy at the skilled nursing facility level. The Plan denied your request. The Plan says your needs are custodial.
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 records show that you are not currently stable for transfer to a lower level of care. You continue to require complex medical care that can be provided at the current long term acute care hospital. 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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on April 20, 2021.
You asked the Plan to pay for an eye refraction. You say that you do not agree with the denial on this claim. You also state the glasses are covered after cataract surgery. The Plan denied your request. The Plan says you cannot receive a refraction only service from an out of network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that an eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. We looked at the file and the Plan's rules. The records show that the service at issue was provided by an out-of-network provider. This service is not covered by the Plan when provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), bone replacement graft for ridge preservation (D7953), and inhalation of nitrous oxide/analgesia (D9230) provided on May 6, 2021.
You asked the Plan to pay for the surgical extraction, bone replacement graft, and inhalation of nitrous oxide/analgesia. You say that this was a medical surgical procedure for your health. You also say that it is not your responsibility to clear a procedure with the Plan. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the surgical extraction (D7210) and bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The contract also clearly states that inhalation of nitrous oxide/analgesia (D9230) is only covered as needed with covered procedures. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210), bone replacement graft for ridge preservation (D7953), and inhalation of nitrous oxide/analgesia (D9230) provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network
(OON) provider on June 3, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay
for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered
by the out-of-network (OON) provider on June 3, 2021.