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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on August 3, 2021.
You asked the Plan to pay for the dental services. You say that it is difficult to keep up with the changes in your policy. You say that you had a claim for x-rays done in February 2020 that was rejected so you thought enough time had passed for them to be covered again. You say that you were experiencing pain and sensitivity in your lower jaw which required an evaluation by your dentist. You also say that you feel that both services were necessary and should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on February 9, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on August 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services provided on November 19, 2020, August 1, 2021, and August 10, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that money is tight, and you are wondering if there is any way to decrease these bills. The Plan denied your request. The Plan says these claims were processed correctly, and your copayments were assessed in accordance with your contract.
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 $350 copayment for ambulance services. You have been asked to pay a $350 copayment or less for each of the ambulance transportation trips. 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 transportation services provided on November 19, 2020, August 1, 2021, and August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered services (99202 and 97140) provided on September 2, 2021.
You asked the Plan to pay for codes 99202 and 97140. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says codes 99202 and 97140 are not covered when billed by a 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 services at issue, codes 99202 and 97140 are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered services (99202 and 97140) provided on September 2, 2021.
Your complaint about not being provided these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve home physician visits for the enrollee.

You asked the Plan to pre-approve the home visits. You say that this is medically necessary. The Plan denied your request. The Plan says home visits are not shown to be medically needed.

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 home visits. Our reviewer says that the requested home visits are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has multiple sclerosis on Ocrevus therapy. He has issues with sitting up and requires a sit-to-stand device. There is no specific clinical rationale for these home visits. The enrollee can be evaluated on a four to six month basis and as-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 home visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve home physician visits for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97162) provided on April 19, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that this service was related to your post-COVID recovery and the copayment should be waived. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $40 copayment for outpatient rehabilitation services. You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation 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 physical therapy services (97162) provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the copayment for a pulmonary function test provided on March 15, 2021.
You asked the Plan to waive the copayment for the pulmonary function test. You say that you did not have a pulmonary function test on this date of service. The Plan denied your request. The Plan says that the copayment applied correctly based on 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. The Plan failed to forward us the medical records that would support the services being billed, we are unable to determine whether the copayment being assessed is correct. Therefore, we decided that the Plan has to waive the copayment for a pulmonary function test provided on March 15, 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the stress test services provided on September 16, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the documentation does not support additional units.

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. 

We looked at the file and the rules. In this case, the Plan has not provided a remittance notice or other claim information to show that the services were previously paid. There is no documentation that the claim at issue was submitted twice. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the stress test services provided on September 16, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gastrointestinal tract capsule endoscopy (91110).

You asked the Plan to pre-approve the gastrointestinal tract capsule endoscopy. The Plan denied your request. The Plan says there are no records of other tests the enrollee has had, or treatments the enrollee has had. The Plan also says that capsule endoscopy is not standard of care for diarrhea.

The Plan follows Medicare rules. Medicare rules say that one indication for a wireless capsule endoscopy is for re-evaluation of persons with Crohn's disease who remain symptomatic despite treatment and there is no suspected or confirmed gastrointestinal obstruction, stricture, or fistulae. 

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 gastrointestinal tract capsule endoscopy. Our reviewer says that the gastrointestinal tract capsule endoscopy is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a history of Crohn's disease currently in remission and is symptom free. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 the gastrointestinal tract capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a gastrointestinal tract capsule endoscopy (91110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of benign non-odontogenic cyst or tumor (D7761) provided on July 29, 2021.
You asked the Plan to pay for the dental service. You say that you had a cyst removed. You say that it was denied as not a covered service. You also say that medical will not cover anything because it was not an accident with your teeth. The Plan denied your request. The Plan says the removal of benign non-odontogenic cyst or tumor 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 removal of benign non-odontogenic cyst or tumor is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of benign non-odontogenic cyst or tumor (D7761) provided on July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 24, 2020, to August 28, 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 the DRG was adjusted in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 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 the services. Our reviewer says that Our physician reviewer found the review indicates that the enrollee's diagnosis was fracture right tibia with nonunion. The reviewed documentation indicates that services initially denied with denial code B for no supporting documentation were approved. Items and services denied with denial code G were upheld for unbundling. These items were determined inclusive to either room and board or the procedure code. The review has determined that the records did not support that the correct DRG and diagnosis were used in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from July 24, 2020, to August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve the IRF care. The Plan denied your request. The Plan says this request is not medically necessary.

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 the 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this patient 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 the IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information does not show that the criteria is met.

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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, there is no documentation of radiculopathy. There is no documentation of inability to tolerate non-invasive/conservative care or medical documentation of failure to respond to four (4) weeks of non-invasive conservative care. The review has determined that the enrollee does not meet the criteria for this injection. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 30, 2019, to January 18, 2020.
You asked the Plan to pay for the SNF care. You say that you were advised by a plan representative that you should have 1 year from the November 11, 2020, denial date to file an appeal. You also say that you believe that this was denied in error. The Plan denied your request. The Plan says the claim for the dates of service in this case was received past the allowed 12 month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the SNF care was not filed until June 22, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 30, 2019, to January 18, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the upper endoscopy procedure (43239) provided on March 24, 2021.
You asked the Plan to reduce the copayment for the endoscopy. You say that you were charged the incorrect copay amount and feel this should have been the $75 diagnostic imaging copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $250 copayment for Medicare-covered outpatient surgery services.
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy in this case was billed with code 43239 which is defined as a biopsy of esophagus, stomach, and/or upper small bowel using a flexible endoscope, and is classified as a surgical procedure. 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 reduce the copayment for the upper endoscopy procedure (43239) provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the copayment for a pulmonary function test provided on April 14, 2021.
You asked the Plan to waive the copayment for the pulmonary function test. You say that you did not have a pulmonary function test on this date of service. The Plan denied your request. The Plan says that the copayment applied correctly based on 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. The Plan failed to forward us the medical records that would support the services being billed, we are unable to determine whether the copayment being assessed is correct. Therefore, we decided that the Plan has to waive the copayment for a pulmonary function test provided on April 14, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on March 17, 2021.

You asked the Plan to pay for the services provided. You say that operative reports were provided. The Plan denied your request. The Plan says the billed code is not supported.

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 63077 is discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single interspace. The CPT Code Manual definition of code 63078 is discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure). 

We looked at the file and the rules. The discectomy services were integral to accomplishing the corpectomy services provided. Accordingly, it is inappropriate to separately report these services based on standard medical and surgical principles. Because the primary code at issue is not payable, the add-on code is also not payable. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay more for the contact lenses provided on June 23, 2021.

You asked the Plan to pay more for the contact lenses. You say that you purchased contact lenses but only received $200. You say that your benefit states you have a $250 allowance for eyewear. The Plan denied your request. The Plan says that you were reimbursed $200 after the withhold amount of $50 was applied.

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 up to $250 every year for eyewear. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the contact lenses have been met. Specifically, the contract says that you pay a $0 copayment for contact lenses from an in-network or out-of-network provider up to the Plan coverage limit. The vision benefit does not state that the Plan will withhold $50 if you purchase eyewear from an out-of-network provider. Therefore, we decided that the Plan has to pay an additional $50 for the contact lenses provided on June 23, 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.