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

We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463) provided on March 25, 2021.
You asked the Plan to waive the copayment for the services. You say that you had a check-up appointment with your primary physician at the doctor's office. You state you received a pneumococcal vaccine during the appointment from the same nurse that checks you in. You state that you were not advised that by receiving the vaccine at the doctor's office you would incur a hospital copayment. The Plan denied your request. The Plan says your visit was billed outpatient hospital based and the Plan must process all claims as they are billed by the provider.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received hospital outpatient clinic services provided on March 25, 2021. The Medicare-allowed amount for the hospital outpatient clinic services is less than the set $250 copayment; therefore, you have been asked to pay the lesser amount of $110.27. Your 2021 EOC states that enrollees must pay a $250 copayment for Medicare-covered surgery or other services or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. 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 hospital outpatient clinic visit for assessment and management of a patient (CPT code G0463) provided on March 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided January 19, 2021.
You asked the Plan to pay for the crown. You say that you were not informed that the provider had opted out of Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare and therefore the services 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. The Plan covers the crown when you see any dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided January 19, 2021.
Your complaint about prior services from this provider being covered 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 waive the copayment for insertion of temporary indwelling bladder catheter; simple (CPT code 51702) provided on October 29, 2020, by a specialist's office.
You asked the Plan to waive the copayment for the specialist office visit. You say that you must have your catheter changed every three (3) to four (4) weeks, which is an office procedure. You state that because this is an office procedure the cost-share should not apply. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file show that you received office services on October 29, 2020, by a specialist. You were asked
to pay a $40 copayment for the services. Your 2020 EOC states that enrollees must pay a $40 copayment for
services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or
physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under
Medicare rules). 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 insertion of temporary
indwelling bladder catheter; simple (CPT code 51702) provided on October 29, 2020, by a specialist's office
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 33285), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says that the enrollee's records show a history of stroke due to a clot that traveled (embolism) to an artery in their brain. The Plan states the enrollee's records indicate no complaints such as palpitations, shortness of breath, or chest pain, and the enrollee does report fatigue that worsens throughout the day. The Plan states they have received no record of any ambulatory/non-invasive monitoring of the enrollee's heart rhythm.
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 service. Our physician reviewer found covered uses for an implantable cardiac loop recorder include the detection, characterization, and documentation of symptomatic transient arrhythmias, which are suspected in this enrollee based on the evidence of strokes. 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 service have been met. Therefore, we decided that the Plan has to pre-approve insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 33285), 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography (74261) to be provided as a screening.
You asked the Plan to pre-approve a CT colonography. You say that this test is necessary, and you would prefer it to the usual test because you feel it is less invasive. The Plan denied your request. The Plan says it is not medically necessary for this test to be provided instead of the usual colonoscopy.
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 CT colonography, 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 computed tomographic (CT) colonography (74261) to be provided as a screening
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on March 18, 2021.
You asked the Plan to pay for the evaluation and x-ray. You say that the enrollee was told these services would be covered, and this cost is a financial hardship. The Plan denied your request. The Plan says that these services can only be covered once every three plan years. You previously had these services in August 2018, which is less than three plan years before the date in question. Therefore, these services exceed the frequency limitations of your benefit and will not be 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. The Plan covers the one comprehensive oral evaluation (D0150) every three plan years and one panoramic x-ray (D0330) every three plan years. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the evaluation and x-ray have been met. Documentation shows that the enrollee previously had the services in question in August of 2018. The Plan argues that it has not been exactly three years between the previous date and the date in question, so these services are denied. However, the contract clearly states that these services may each be covered once every three plan years. The contract does not specify that services must be provided 36 months apart or that this benefit is applied on a rolling year from the last date of service. 2018 and 2021 are three plan years apart. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on March 18, 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 pay for the podiatry services provided on June 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON podiatry services. You say that the services are medically necessary. The Plan denied your request. The Plan says these services were provided out of network without authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 podiatry services provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May
12, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to
pay this copayment because the ride was very rough, and it could have affected your recovery. The Plan denied
your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed
amount for this transport ($218.50) is less than your copayment obligation, you are responsible for the full
allowed 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 $275
copayment for ambulance services.
You have been asked to pay a $275 copayment for the ambulance services. This copayment applies regardless
of your satisfaction with the transport. 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 ambulance services
you received on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99336) provided on May 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that it is the responsibility of the nursing facility to obtain prior authorization. These services were necessary and provided in good faith. The Plan denied your request. The Plan says in general, the Plan does not cover out-of-network services. Prior authorization was not obtained for this care, and it cannot be determined that the services in nature were urgent or emergent as no medical records were provided as requested.
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 rules also say that the provider, supplier or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 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. No medical records were provided to verify if the services in question were urgent or emergent. 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 home visit (99336) provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(CPT code D0150) and intraoral - complete series of radiographic images (CPT code D0210) provided on June
14, 2021.
You asked the Plan to pay for the dental services. You say that you needed to go to a new dentist for a proper
full exam/cleaning/x-rays. You state you were under the impression that you had two (2) exams per calendar
year. The Plan denied your request. The Plan says you exhausted your benefit.
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.
Review of the file shows the procedures D0150 and D0210, were previously paid on March 02, 2020, for date
of service January 31, 2020. Therefore, you exhausted your benefit. Your 2021 EOC states, D0150 -
Comprehensive exam - one (1) procedure every three (3) plan years. D0210 - Intraoral complete series - one
procedure every three plan years. Therefore, we decided that the Plan does not have to pay for comprehensive
oral evaluation - new or established patient (CPT code D0150) and intraoral - complete series of radiographic
images (CPT code D0210) provided on June 14, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 10, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that you had a hip replacement and are making progress.
You state that if you are discharged you may never walk again without the physical therapy. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found no documented skilled nursing needs. Based
on review of the records, you did not meet the Centers for Medicare & Medicaid Services (CMS) coverage
criteria for a stay in the SNF. Your stay in the SNF was not reasonable and not medically necessary for you,
who has had post-operation patient's prior level of function (PLOF) hip replacement with PLOF dependency.
You did not need any nursing care other than routine care. You had no skilled nursing needs such as
intravenous (IV) medications or skin care. Documentation does not support the need for a stay in SNF with
daily skilled therapies in an inpatient setting. Your care needs could have been safely provided at an alternate
and lower intensity setting such as in a long-term care (LTC) facility with intermittent therapies.
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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care from October 10, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) evaluation provided on December 6, 2019.
You asked the Plan to pay for the PT evaluation. You say that these services are correctly coded and should be paid. The Plan denied your request. The Plan says this is not coded correctly.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist may only be billed by a physician as "incident-to" services if there is direct supervision. The services at issue were rendered by a PT in the home but were billed by the physician. Payment cannot be made to the physician as the physician was not physically present in the enrollee's home. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) evaluation provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a status indicator of 3 and no PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on May 5, 2021, at an urgent care center.
You asked the Plan to waive the copayment for the urgent care office visit. You say that this was just a regular appointment and was billed incorrectly. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. The service at issue was provided in an urgent care center, and this is confirmed by medical records.
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 urgently needed services. You have been asked to pay a $40 copayment for the urgent care visit. The visit was provided at an urgent care center and falls within the urgently needed 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 office visit (99214) provided on May 5, 2021, at an urgent care center.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve frontal sinus (area between the nose and eyes), maxillary antrostomy (opening of the area on the sides of the nose), and ethmoidectomy (removal of ethmoid bone in the sinus) (CPT code(s) 31267-50, 31255-50, and 31276-50), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee is in bad pain and needs this surgery. The Plan denied your request. The Plan says the clinical value and effectiveness of Functional Endoscopic Sinus Surgery in the setting of a computed tomography (CT) scan of the sinuses noting only mild mucosal thickening to the ethmoid and maxillary sinuses with clear ostiomeatal complexes, sphenoid sinuses, spheno-ethmoidal sinuses, and nasal turbinates have not been demonstrated in the peer-reviewed literature.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the documentation is insufficient to demonstrate that functional endoscopic sinus surgery of the frontal, maxillary, and ethmoid sinuses is medically reasonable and necessary for the enrollee in this case. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve frontal sinus (area between the nose and eyes), maxillary antrostomy (opening of the area on the sides of the nose), and ethmoidectomy (removal of ethmoid bone in the sinus) (CPT code(s) 31267-50, 31255-50, and 31276-50), for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling provided for tooth #22 provided on October 30, 2020.
You asked the Plan to pay for the filling. You say that you do not know that you had this filling on the same tooth. You feel that the provider should have told you it wouldn't be covered. The Plan denied your request. The Plan says you had a filling on this same tooth less than 3 years prior to the date of 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, fillings are only covered once every 36 months for the same tooth. Therefore, we decided that the Plan does not have to pay for the filling provided for tooth #22 provided on October 30, 2020.