Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for laboratory services (88312, 88305) rendered on October 1, 2021.  You asked the Plan to pay for laboratory services. You say that you currently work with a number of doctor groups, who are participating providers. You also say the patient does not go to your lab, so he/she is not using out-of-network benefits as his/her participating doctor sends you the specimens to process. The Plan denied your request. The Plan says that a grievance and appeal specialist reviewed all the information, and based on this information the Plan determined that they would maintain their original decision to not pay the laboratory services.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for laboratory services by a contract provider. The file does not show that the plan provided notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory services (88312, 88305) rendered on October 1, 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: Unfavorable

 We decided that the Plan does not have to pre-approve six office visits to be rendered by the OON provider.  You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve six office visits to be rendered by the OON provider.
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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation needs require an inpatient stay and close physician/ nursing supervision. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.  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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for metabolic encephalopathy and urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. 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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a screening mammography (77067) and screening breast tomosynthesis (77063) provided on August 6, 2021.  You asked the Plan to pay for a screening mammography and screening breast tomosynthesis. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  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 directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for a screening mammography and screening breast tomosynthesis until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for a screening mammography (77067) and screening breast tomosynthesis (77063) provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation treatments provided from September 21, 2021, to September 22, 2021.  You asked the Plan to waive the coinsurance for radiation treatments. You say that the provider told you that they would cover the charges but are not and you cannot afford them. 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 20% coinsurance for therapeutic services.    You received radiation treatments from September 21, 2021, to September 22, 2201. Radiation treatments are considered a therapeutic service. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $530.16 and 20% of that is $106.04.   You have been asked to pay the total coinsurance amount of $106.04 for radiation treatments. Radiation treatments 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 coinsurance for radiation treatments provided from September 21, 2021, to September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on March 17, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the provider is out-of-network and the member does not have out-of-network benefits.  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 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 an eye refraction provided on March 17, 2021.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to waive the copayment for a colonoscopy provided on May 26, 2021.  

You asked the Plan to waive the copayment for a colonoscopy. You say that this was a preventative procedure and you cannot afford the charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.  

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 did not provide medical records. Without medical records we cannot determine whether the services should be considered preventative or diagnostic. The Plan also did not provide any documentation showing that the colorectal cancer screening benefit had been exhausted prior to services being rendered. Therefore, we decided that the Plan has to waive the copayment for a colonoscopy provided on May 26, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided
from October 26, 2021, to November 24, 2021.

You asked the Plan to waive the copayments for the PT services. You say that your case manager informed you
that the home physical therapy visits would be free. The Plan denied your request. The Plan says you have been
charged the correct cost sharing 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 $30
copayment for each therapy visit.

The record shows you had a total of 10 PT visits from October 26, 2021, to November 24, 2021. You have
been asked to pay a $30 copayment for each therapy visit, for a total of $300 ($30 copayment x 10 visits =
$300). The PT 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 physical therapy (PT) services provided from October 26, 2021, to
November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 3 extractions (D7210), and bone replacement graft (D7953 x 3) provided on August 18, 2021.  You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that this provider was in network. You say that these services were medically necessary. You also say that The Plan denied your request. The Plan says dental services received out of network are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, dental services are only covered when received by a participating provider. Additionally, bone replacement grafts are not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the 3 extractions (D7210), and bone replacement graft (D7953 x 3) provided on August 18, 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 lab services. The Plan denied your request. The Plan says these services are not payable.  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. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 20, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you would like to be reimbursed for this service. The Plan denied your request. The Plan says this procedure is not covered under your 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 cone beam computed tomography (CT) capture and interpretation (D0364) provided on September 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on September 6, 2021.  

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you fell ill with pain in your abdomen, and you couldn't drive or stand and your husband does not drive so you called the ambulance company. You say they checked you out and couldn't find anything and stated if you are still in pain to call them again. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. If no transport of a Medicare beneficiary occurs, then there is no Medicare covered services.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   

The ambulance company did not provide transport services on September 6, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on September 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 2021.

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 appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emotional and behavior assessment provided on September 15, 2021.

You asked the Plan to waive the copayment for an emotional and behavior assessment. You say that you called for a prescription and did not receive a behavioral health evaluation. 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 $20 copayment for outpatient diagnostic procedures or tests. 

The medical records show that you received an emotional and behavior assessment on September 15, 2021. An emotional and behavior assessment is considered an outpatient diagnostic test. Therefore, you are responsible to pay the allowed amount of $5.63, which is less than the $20 copayment. 

You have been asked to pay $5.63 for an emotional and behavior assessment. An emotional and behavior assessment falls 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 an emotional and behavior assessment provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you could receive care in another setting and the Plan could review alternate settings if requested such as a skilled nursing facility, outpatient setting or home with home health care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a right foot infection and had a below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve stab phlebectomy for the enrollee.  You asked the Plan to pre-approve the surgery. You say that the enrollee has a long-standing history of right lower extremity veins. The Plan denied your request. The Plan says that there is no documentation in the medical record that the right lower extremity edema had been refractory to any previous treatment.  The Plan must follow Medicare rules. Medicare rules say that varicose vein treatment can be covered if there is documentation of persistent symptoms despite conservative treatment.  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 surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is satisfactory documentation that the enrollee has persistent edema refractory to a greater than six-week period of medical grade compression stocking use. There is satisfactory documentation that there is no significant reflux in the truncal greater saphenous vein. There is also satisfactory documentation that the varicosities in question are greater than 4 mm in diameter.  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 surgery have been met. Therefore, we decided that the Plan has to pre-approve stab phlebectomy for the enrollee.   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 an anterior resin-based composite (D2332) and a posterior resin-based composite (D2393) provided on September 13, 2021, to September 17, 2021.  

You asked the Plan to pay for an anterior resin-based composite and a posterior resin-based composite. You say that your provider did not communicate that your two fillings had been charged for 2021 and you cannot afford this expense. The Plan denied your request. The Plan says you have been issued reimbursement for two fillings; therefore, the service has exceeded frequency.  

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 an anterior resin-based composite and a posterior resin-based composite twice per calendar year.    

We looked at the file and Medicare rules. The records show that you received an anterior resin-based composite and a posterior resin-based composite on March 23, 2021 and June 30, 2021, therefore, you have exhausted your maximum benefit for these services. Based on this information, we decided that the Plan's rules for coverage of an anterior resin-based composite and a posterior resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay for an anterior resin-based composite (D2332) and a posterior resin-based composite (D2393) provided on September 13, 2021, to September 17, 2021.