Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided on May 24, 2021.

You asked the Plan to waive the copayment for physician services. You say that you want the Plan to reconsider your claims. The Plan denied your request. The Plan says you were charged the 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 $25 copayment for Physician Services, Specialist's Office. 

You have been asked to pay $25 copayment for physician services. Physician services fall within the Physician Services, Specialist's Office 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 physician services provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.

You asked the Plan to provide additional routine transportation. You say that you need this transportation to get to your necessary appointments. The Plan denied your request. The Plan says you have exceeded your routine transportation benefit. Routine transport in excess of the 42 rides provided by your supplemental benefit is not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 42 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
October 17, 2019, to November 1, 2019.
You asked the Plan to pay for home health services. You say that these services do not require authorization.
The Plan denied your request. The Plan says these services were not billed correctly.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a Q code
was not billed on this claim to report the service location. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from October 17, 2019, to November 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management provided on September 30, 2020.

You asked the Plan to pay for hospital discharge day management; 30 minutes or less (99238). You say that the Plan should pay this claim. The Plan denied your request. The Plan says Original Medicare is responsible for the denied services.

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 September 26, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital discharge day management provided on September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology and tissue examination (88305 and 88173) provided on May 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you work with participating providers and do not see the patients. The Plan denied your request. The Plan says this out-of-network service was not urgent, emergent or 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 cytopathology and tissue examination (88305 and 88173) provided on May 6, 2021 by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy services provided from March 1, 2021, through March 31, 2021.
You asked the Plan to waive the copayment for radiation therapy services. You say that your husband looked up the benefits and it said everything was going to be covered 100%. You say that you don't want the cost to be something that it shouldn't be. The Plan denied your request. The Plan says the copayments 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 $50 copayment per visit for Medicare-covered therapeutic radiology services.
You have been asked to pay a $50 copayment for each radiation therapy service. The total amount you owe is $1,150 ($50/visit x 23 visits = $1,150). Radiation therapy services fall 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 radiation therapy services provided from March 1, 2021, through March 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit provided on May 27, 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 the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment per emergency department visit. 

You have been asked to pay a $65 copayment for the emergency department visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the resin-based composite - one surface, posterior (D2391) and remove broken implant retaining screw (D6096) provided April 22, 2021.
You asked the Plan to provide additional payment for the resin-based composite and removal of broken implant retaining screw. You say that it was necessary to replace the loose implant screw. The Plan denied your request. The Plan says the resin-based composite was paid at the maximum allowable charge and the removal of broken implant retaining screw 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.
The Plan only pays up to a certain amount for service provided out-of-network (OON). If you choose to see an OON dentist, you might be billed for any amount greater than what the plan pays. We looked at the file and Medicare rules. The Plan provided coverage of the resin-based composite up to the contracted rate. You are responsible for any costs greater than what the Plan pays. Though the Plan offers dental benefits in excess of Medicare coverage, the removal of broken implant retaining screws is not a covered service. Therefore, we decided that the Plan does not have to provide additional payment for the resin-based composite - one surface, posterior (D2391) and remove broken implant retaining screw (D6096) provided April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac device monitoring services (93293} provided on March 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that you provided this service out of good faith. Therefore, you expect proper reimbursement for your service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 cardiac device monitoring services (93293} provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87541, 87581, 87640, 87798) provided on August 3, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87541, 87581, 87640, 87798) provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 2, 2021.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an assisted living facility setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 2, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a nuclear stress test.

You asked the Plan to pre-approve a nuclear stress test. You say that the enrollee has a history of coronary artery disease with stenting in 2011 and 2012. You say that the enrollee has not had any imaging to evaluate her disease since 2019. You also say that this is medically necessary. The Plan denied your request. The Plan says that the requested nuclear stress test is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated for the risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms who have not had a revascularization procedure within the past two years. 

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 a nuclear stress test. Our reviewer says that the nuclear stress test is medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee is asymptomatic. The reviewer found that it has been more than two years since the enrollee's stenting procedure and more than two years since her prior SPECT nuclear ischemic assessment. The reviewer found that cardiovascular nuclear imaging is indicated for the risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms who have not had a revascularization procedure within the past two years. Therefore, the reviewer found that the requested testing is medically reasonable and 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 a nuclear stress test have been met. Specifically, the file indicates that the enrollee has not had any imaging to evaluate the disease in more than 2 years. Therefore, we decided that the Plan has to pre-approve a nuclear stress test.

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 bone graft for ridge preservation (D7953) provided on June 28, 2021.
You asked the Plan to pay for the dental service. You say that the doctor performed this procedure because you are allergic to the removable denture prosthesis. The Plan denied your request. The Plan says bone replacement graft for ridge preservation is not listed as a covered dental 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 bone replacement graft is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone graft for ridge preservation (D7953) provided on June 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that continued therapy is necessary to further improve the enrollee's level of assistance needed. The Plan denied your request. The Plan says the skills of a therapist are not necessary to attain goals.
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 additional services. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy.
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 performed only by a therapist, or under the supervision of a therapist. He has been instructed in safety precautions as well as a home exercise program and approved of additional therapy to ensure competence in this program. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist are not required to establish, design or deliver a program to maintain his current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the crowns (D2740 x 2) and core build up (D2950) provided on May 12, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you do not understand how the services you had in May exceed the limit. You say that was your first visit to the dentist for the year. You also say that you have $2,000 in dental coverage. The Plan denied your request. The Plan says there is a maximum combined allowance of $2,000 every year for covered preventive and comprehensive dental services. The Plan says that the maximum allowance has been exhausted while processing this claim.
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 dental services when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the record shows that the maximum allowance has been exhausted. The record shows that the Plan paid $400 for the dental services you received on April 27, 2021, and $1,600 towards a crown that you received on May 12, 2021. $400+$1,600=$2,000. Therefore, we decided that the Plan does not have to pay an additional amount for the crowns (D2740 x 2) and core build up (D2950) provided on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on March 1, 2021.

You asked the Plan to pay for the custom fabricated abutment (D6057) and abutment supported crown (D6058). You say that you don't understand rejecting a crown service when it is supposed to be covered. You say that this appears to be based on coding differences. The Plan denied your request. The Plan says the services are not covered benefits.

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 custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on March 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you would like an extension to rehabilitation services. The Plan denied your request. The Plan says that you no longer require daily skilled services.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.
 
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) (D0367) provided on June 3, 2021.
You asked the Plan to pay for the dental service. You say that you were told there was a problem with your tooth, and they would do an x-ray. The Plan denied your request. The Plan says cone beam CT is not listed as a covered dental 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 cone beam CT is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) (D0367) provided on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73552 and 73030 provided on June 5, 2021.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 73552 and 73030 are not supported in the medical record. Specifically, the documentation supports one unit of each of these codes. The documentation also supports that these were previously approved and paid. There is no additional documentation supporting additional studies which were billed.

Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73552 and 73030 provided on June 5, 2021.