Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest (71260) and of the abdomen and pelvis (74177).

You asked the Plan to pre-approve CTs of the chest and of the abdomen and pelvis. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 CTs of the chest and of the abdomen and pelvis. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that you have undergone staging CT scans. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested services at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTs of the chest and of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest (71260) and of the abdomen and pelvis (74177).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from April 1, 2021, to April 29, 2021.  You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were not made aware that you would owe a copayment for outpatient rehabilitation services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 outpatient rehabilitation services.   You received outpatient rehabilitation services from April 1, 2021, to April 29, 2021, for a total of 7 visits.   Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 (copayment) x 7 (outpatient rehabilitation services) = $245.   You have been asked to pay the total copayment amount of $245 for outpatient rehabilitation services. Outpatient rehabilitation services fall 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 copayments for outpatient rehabilitation services provided from April 1, 2021, to April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 7, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to pay this bill because it was the provider's fault for not watching the enrollee correctly, requiring him to have to be transferred to another hospital. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment per trip for ambulance services. 

The enrollee has been asked to pay a $250 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.

This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the central venous access device removal rendered on October 16, 2020.  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 payment is included in the global surgical package.  The Plan must follow Medicare rules. The rules say that follow-up services related to the original surgery are included in the global surgical package.  We looked at the file and Medicare rules. The file shows that procedure code 36590 (removal of tunneled central venous access device) was billed within the 10-day global surgical period of procedure 36558 (insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older), performed on October 16, 2020, and is related to the original procedure. Payment for 36590 is included in the global surgical package for this procedure. Therefore, we decided that the Plan does not have to pay for the central venous access device removal rendered on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye exam provided on February 16, 2021.  

You asked the Plan to pay for an eye exam. You say that an employee at this vision center told you that they accepted your Plan for coverage. The Plan denied your request. The Plan says routine eye exams must be obtained from a provider in the Plan's vision vendor network.  

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network.  

We looked at the file and the Plan's rules. The file shows that the eye exam was not provided from a provider in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a specialist (92014) provided on July 13, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that these claims are inaccurate because you saw a different doctor at this office, and you have already paid 50% out-of-pocket for these services. The Plan denied your request. The Plan says there is a $40 copayment for office visits with a specialist.
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 $30 copayment for an office visit with a specialist.
You have been asked to pay a $30 copayment for the specialist office visit. The office visit in question was with an ophthalmologist, which is a type of specialist. 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 office visit with a specialist (92014) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on November 19, 2020.  You asked the Plan to pay for the gingivectomy or gingivoplasty. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's dental plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment (D0601) and three additional intraoral periapical x-rays (D0230 x3) provided on August 18, 2021.
You asked the Plan to pay for the caries risk assessment and three additional intraoral periapical x-rays. You say that you are on a fixed income and cannot afford to pay this dental bill. The Plan denied your request. The Plan says the caries risk assessment is not covered under your benefit plan. The Plan also says that intraoral periapical x-rays are limited to two times per calendar year, and you have reached this limit for this 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, caries risk assessment (D0601) is not among those covered under this benefit. The contract says that preventive x-rays are limited to two of either codes D0220, D0230, D0270, D0272, D0273, or D0274 per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) on August 18, 2021 which were covered by the Plan and your preventive x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the caries risk assessment (D0601) and three additional intraoral periapical x-rays (D0230 x3) provided on August 18, 2021.
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 IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 you do not require the intensity of services provided at an IRF.

Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy (PT) services to be rendered by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the PT services. The Plan denied your request. The Plan says you must use Plan providers in order for services to be covered. The Plan also says that there are participating providers with the appropriate training and experience to provide the requested service.  

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) services to be rendered by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88112, 88121) provided May 6, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service was not billed with a valid diagnosis code for this testing. Testing for screening purposes is non-covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, genetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (88112, 88121) provided May 6, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for a bone mass measurement provided on July 19, 2021.
You asked the Plan to waive the copayment for a bone mass measurement. You say that this was a screening and you should not owe anything for the services. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct 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 there are no cost-sharing charges for bone mass measurements. For qualified individuals, the following services are covered every 24 months or more frequently if medically necessary. The Plan says you must pay $132.14 for a bone mass measurement. Based on the Plan contract, however, you cannot be asked to pay for a bone mass measurement. The Plan did not provide any documentation showing that his benefit was exhausted, nor that the services rendered were diagnostic in nature. Therefore, we decided that the Plan has to waive the copayment for a bone mass measurement provided on July 19, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ensure, enteral nutrition.  You asked the Plan to pre-approve Ensure. You say that this is the only thing that you eat with some soup throughout the day. You also say that this is the only milk you like, and it helps with your overall health. The Plan denied your request. The Plan says Ensure is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Ensure, enteral nutrition.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a respiratory pathogen screening panel (87496, 87532, 87541, 87640, 87798) provided on August 3, 2021.
You asked the Plan to pre-approve a respiratory pathogen screening panel. You say that this should be covered. The Plan denied your request. The Plan says this was not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a respiratory pathogen screening panel, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve a respiratory pathogen screening panel (87496, 87532, 87541, 87640, 87798) provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair lift.  

You asked the Plan to pre-approve a stair lift. You say that your primary care physician is deeming it medically necessary for the enrollee to have a stair lift. The Plan denied your request. The Plan says this item is not a covered benefit.  

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (00300) provided on September 18,
2020.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based
on the medical documentation. The Plan denied your request. The Plan says they are the secondary insurance
payer and not liable for payment until the primary payer has denied payment.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed the
provider to bill the enrollee's primary insurance payer in the decision letter that was issued. As the secondary
insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has denied the
claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia services
(00300) provided on September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on May 30, 2021.

You asked the Plan to pay for cerebral perfusion analysis. You say that this is supported in the records. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that limited diagnosis codes support medical necessity of cerebral perfusion analysis. The diagnosis codes that support medical necessity are I63.031, I63.032, I63.131, I63.132, I63.311, I63.312, I63.411, I63.412, I63.511, and I63.512. 

We looked at the file and Medicare rules. The service at issue was not billed with a diagnosis code that supports medical necessity. Based on this information, we decided that Medicare rules for coverage of cerebral perfusion analysis have not been met. Therefore, we decided that the Plan does not have to pay for cerebral perfusion analysis (0042T) provided on May 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay.

You asked the Plan to pre-approve the SNF stay. The Plan denied your request. The Plan says you appear to have optimized your progress through skilled therapy services, and at this time your needs appear to be custodial in nature.

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 the SNF stay. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

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 SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM (99053) provided on May 7, 2021.

You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 99053 has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into payment for other service.

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 99053 is not supported in the record. Specifically, CPT code 99053 has a status indicator of B.

This means that the payment for CPT code 99053 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM (99053) provided on May 7, 2021.