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

 We decided that the Plan does not have to pay for the full mouth x-ray (D0210) and oral hygiene instructions (D1330) provided from March 10, 2021, to September 13, 2021.  

You asked the Plan to pay for the dental services. You say that the services should be covered. You say that you were advised you received routine x-rays and not full mouth x-rays in 2020. You also say that you were advised the last full mouth x-ray you received was almost 6 years ago. The Plan denied your request. The Plan says full mouth x-rays, including bitewing x-rays, are covered once every 5 years. The Plan says that the frequency limit has been exceeded. The Plan also says oral hygiene instruction 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 and full mouth x-ray is listed as covered, the frequency limit has been exceeded. The record shows that full mouth x-rays share a frequency limit with bitewing x-rays. The record also shows that the Plan paid for bitewing x-rays that you received on March 2, 2020. Additionally, oral hygiene instruction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth x-ray (D0210) and oral hygiene instructions (D1330) provided from March 10, 2021, to September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the knee orthosis (L1852).  You asked the Plan to pre-approve the knee orthosis. You say that this is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the submitted documentation does not show a recent injury or surgery or that you are unable to walk and have had exam that shows your knee is unstable.  The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is covered for enrollees who have either a recent injury/surgery or documented knee instability.  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 knee orthosis. Our reviewer says that the requested orthosis is not medically reasonable and necessary. Our physician reviewer found there is no objective evidence of pathological laxity or instability on a physical exam of the knee. There is no evidence of a recent surgery or injury to the knee. The patient is noted to be ambulatory but there is no evidence that the patient requires the requested knee brace.  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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1852).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88305, 88312, 88313) rendered by the out-of-network (OON) provider on June 8, 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 (88305, 88312, 88313) rendered by the out-of-network (OON) provider on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 5, 2021.  

You asked the Plan to pay for the services provided. You say that there is no contractual agreement which indicates the codes are included in the dialysis rate. The Plan denied your request. The Plan says the services are not paid separately.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed.    

Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies (A4221) provided to the enrollee from August 24, 2020, to September 1, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory  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 supplies (A4221) provided to the enrollee from August 24, 2020, to September 1, 2020.
Appeal type: Hospice
Decision: Favorable

 We decided that the Plan has to pay for the closure of the lacrimal punctum (68671), and Ophthalmological services (92014 and 92134), provided on November 5, 2019.  You asked the Plan to pay for the closure of the lacrimal punctum and Ophthalmological services. You say that the services should be covered. The Plan denied your request. The Plan says that the member was in hospice during the date of service.  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 forwarded any evidence that the member was enrolled in hospice on the billed date of service or any time during the month of November. The documentation provided indicates that the member's hospice election ended in October. Therefore, we decided that the Plan has to pay for the closure of the lacrimal punctum (68671), and Ophthalmological services (92014 and 92134), provided on November 5, 2019.   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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on February 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that the rendering physician is a Hospitalist physician and depends upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and OON provider from the enrollee's insurance company. You also say that the facility failed to obtain the necessary authorization for this enrollee. The Plan denied your request. The Plan says prior authorization was not obtained.  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 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 domiciliary or rest home visit (99336) provided on February 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam and eyewear rendered on June 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 the provider is not a 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 covers routine vision services from a network provider only.  We looked at the file and the Plan's rules. The file shows that you received services from a provider that is not in the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam and eyewear rendered on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the embedded foreign body removal (40804) provided on August 10, 2021.  You asked the Plan to pay for the embedded foreign body removal (40804). You say that the primary care physician ordered the procedure and medical providers must render treatment. You say that the provider followed the guidelines and criteria set and the claim should be processed for payment. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 code 40804 is not supported in the medical record. Specifically, CPT code 40804 has a payment indicator of N1 when performed at an ambulatory surgical center. This means that no separate payment can be issued. Based on this information, we decided that Medicare rules for coverage of the embedded foreign body removal (40804) have not been met. Therefore, we decided that the Plan does not have to pay for the embedded foreign body removal (40804) provided on August 10, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy.  You asked the Plan to pre-approve laparoscopic sleeve gastrectomy. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have:   (1) a body mass index (BMI) of greater than or equal to 35;   (2) at least one co-morbidity related to obesity; and  (3) been unsuccessful with medical treatment for obesity.    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 laparoscopic sleeve gastrectomy. Our reviewer says that the requested service is medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a body mass index of 61 and has hyperlipidemia, hepatic steatosis, and metabolic syndrome. She has failed medical management for the treatment of obesity. The elements of the coverage rules are satisfied. The requested service is recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laparoscopic sleeve gastrectomy have been met. Therefore, we decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy.   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound (76830) provided on August 16, 2021.  You asked the Plan to waive the copayment for an ultrasound. You say that you were told there would be no 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 $125 copayment for outpatient diagnostic tests.   You have been asked to pay a $125 copayment for an ultrasound. The service at issue falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound (76830) provided on August 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) provided on March 31, 2021.  

You asked the Plan to pay for the CT. You say that the enrollee was not enrolled in hospice until April 26, 2021. You also say that you would like this claim to be reprocessed for payment. 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 enrollee's terminal condition.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  

The enrollee ended Medicare Hospice benefits on March 29, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99212) therapeutic activities (97530) mechanical traction (97012) provided May 27, 2021 to June 4, 2021.  

You asked the Plan to pay for the chiropractic services. You say that you do not understand why the chiropractic services are not covered. The Plan denied your request. The Plan says these services are not covered when rendered by chiropractor.  

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 outpatient office visit (99212) therapeutic activities (97530) mechanical traction (97012) provided May 27, 2021 to June 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the inpatient hospital admission and services provided July 11, 2021, to July 13, 2021.  

You asked the Plan to waive the cost sharing for the inpatient hospital services. You say that you were misdiagnosed and should not be responsible for the cost of an unnecessary hospital stay. The Plan denied your request. The Plan says the cost-sharing has been 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 10% coinsurance for Inpatient hospital care up to the out-of-pocket maximum of $1,150.   

You have been asked to pay $675.43 for the inpatient hospital services. At the time of the services, you had $675.43 remaining in your out-of-pocket maximum. 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 sharing for the inpatient hospital admission and services provided July 11, 2021, to July 13, 2021.   

The Qualified Independent Contractor read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for anesthesia services (00811) rendered on August 11, 2021.  You asked the Plan to waive the deductible for anesthesia services. You say that this claim was provided during a covered procedure by a physician within your network and you were not given an option of which anesthesiologist to use or given the information that he was not in your coverage network. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that the "deductible" is the amount you must pay for medical services before the Plan begins to pay its share. The Plan contract says that there is a $1,000 deductible for all items and services except those specifically excluded by the Plan contract. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The Plan deductible applies to anesthesia services.  You have been asked to pay $113.25 towards your $1,000 deductible for anesthesia services. Anesthesia services fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center. This deductible is part of the cost sharing that is a contractual obligation that had not been met at the time anesthesia services was received on August 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for anesthesia services (00811) rendered on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a CT scan of the head (70450) provided on August 4, 2021.  You asked the Plan to waive the deductible for the CT scan. You say that the services should be covered as the Plans EOC contradicts itself and the services should be covered in-network because of covid-19. 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. Your contract with the Plan says that there is a $750 deductible which applies to Outpatient diagnostic tests and therapeutic services and supplies.   The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to Out-of-network Outpatient diagnostic tests and therapeutic services and supplies. There are no Plan guidelines stating that services should be billed in-network due to covid. This cost sharing is a contractual obligation that had not been met at the time the CT scan was received on August 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a CT scan of the head (70450) provided on August 4, 2021.
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 this type of procedure is not covered because it is still considered investigational and still under study.  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 this device is experimental. More research is needed.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation and management services provided on August 17, 2021.  You asked the Plan to pay for the services provided. You say that the service was medically necessary. The Plan denied your request. The Plan says the reporting of the code does not follow industry standard coding rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   The file shows that CPT code 99214 was billed with modifier 25. The medical records provided show the enrollee received an office visit, during which time osteopathic manipulation was provided. The records do not show that a significant, separately identifiable evaluation was provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services provided on August 17, 2021.