Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of subcutaneous tissue (11042 and 11045) and home visit (99349) provided on March 3, 2021 by an OON provider.

You asked the Plan to pay for the debridement of subcutaneous tissue (11042 and 11045) and home visit (99349). You say that you would like to appeal for retroactive authorization based on medical necessity. The Plan denied your request. The Plan says the enrollee was not referred by their primary care physician. The Plan also says that these services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 debridement of subcutaneous tissue (11042 and 11045) and home visit (99349) provided on March 3, 2021 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 48 transportation trips (A0120).

You asked the Plan to pre-approve an additional 48 transportation trips. You say that you need additional trips. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 48 transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (D9440) provided on May 20, 2020.

You asked the Plan to pay for the office visit. You say that you did not know the treating provider was out-of-network.
You also say that you were not told this visit would be considered an emergency visit and would be
charged accordingly. The Plan denied your request. The Plan says your contract does not cover this service.
The Plan also says that the dental office was closed during the pandemic, seeing only emergency visits, and
payment for this request cannot be approved.

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 office
visit (D9440) provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON service. You say that the enrollee had a complex problem requiring surgery and treatment. The Plan denied your request. The Plan says prior authorization is required for non-participating providers.
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 file shows the enrollee was seen for a surveillance examination. The 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 the office visit provided on April 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit (CPT code 99203) provided on April 8, 2021, by an in-network provider.
You asked the Plan to waive the deductible for the office visit. You say that you are under the belief that you have a responsibility due on the claim because the provider is out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 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 shows that you received office services on April 8, 2021, by an in-network provider. Although this is an in-network provider, at the time of services rendered you had not met your $203 deductible; therefore, you have been asked to pay $104.28 for the services to apply to your deductible. 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 deductible for the office visit (CPT code 99203) provided on April 8, 2021, by an in-network 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 member has rehabilitation needs to improve strength, endurance, activities of daily living and mobility as well as medical needs that require daily medical oversight. The Plan denied your request. The Plan says that the member does not have complex or intensive rehabilitation needs.
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 aortic and tricuspid valve replacements which were complicated by new stroke with hemiparesis. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two procedures to remove of lateral exostosis (D7471).
You asked the Plan to pre-approve the dental procedure. You say that this service is medically necessary as you are experiencing pain and difficulty eating. The Plan denied your request. The Plan says this service is not covered by your dental 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.
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 pre-approve two procedures to remove of lateral exostosis (D7471).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neuromuscular electrical stimulator to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a neuromuscular electrical stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been ordered by your neurosurgeon as part of the recommended treatment plan.
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 if it was determined this equipment would be medically necessary. 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 a neuromuscular electrical stimulator to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health visit provided on June 14, 2021.

You asked the Plan to waive the copayment for the outpatient mental health care visit. You say that you do not want to pay the copayment because you were not aware of the end of the waiver. The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment for each Medicare-covered individual or group visit.

You have been asked to pay a $35 copayment for the outpatient mental health care visit. The outpatient mental health care visit falls within the "Outpatient mental health care" 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 outpatient mental health visit provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 17, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says lab tests must be ordered by the physician who is treating the enrollee.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and the rules. We find that the testing services are not supported in the records. The records do not indicate the enrollee's treating physician ordered the testing and would use the results in the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided
by a participating provider from February 17, 2021, to April 7, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you do not agree
with these copayments. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $30 copayment for outpatient rehabilitation services/in-network.
The enrollee has been asked to pay a $30 copayment for outpatient rehabilitation services. The total amount
you are being asked to pay is $600 ($30 x 20 = $600). The correct copayments have been applied to the
services that were provided. Outpatient rehabilitation services fall within the outpatient rehabilitation
services/in-network benefit category. 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
outpatient rehabilitation services provided by a participating provider from February 17, 2021, to April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the photodynamic therapy services coded 96573 provided on April 6, 2021.
You asked the Plan to pay for the photodynamic therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 96573 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the photodynamic therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the photodynamic therapy services coded 96573 provided on April 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on December 2, 2020 and December 8, 2020.

You asked the Plan to waive the copayments for the ambulance rides. You say that the ambulance services should be covered at 100% because these were coronavirus related. The Plan denied your request. The Plan says you have been asked to pay 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 $300 copayment for each Medicare-covered one-way trip via ground ambulance trip.

You have been asked to pay a $300 copayment for the ambulance ride on each date of service. The ambulance rides fall within the "Ambulance services" benefit category. Please note, there is no provision in the contract stating a copayment would be waived due to the coronavirus. 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 the ambulance rides provided on December 2, 2020 and December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the magnetic resonance imaging (MRI) of
the pelvis (72197) provided on December 10, 2020.
You asked the Plan to waive the deductible for the MRI of the pelvis. You say that you would like this cost
share waived. The Plan denied your request. The Plan says the cost share has processed correctly at this time.
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 is a $500 deductible which applies to radiological diagnostic services.
The item or service you asked the Plan to waive the deductible for falls within the benefit category radiological
diagnostic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$500 deductible which applies to radiological diagnostic services. This cost sharing is a contractual obligation
that had not been met at the time the MRI of the pelvis was received on December 10, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for the magnetic resonance imaging (MRI) of the
pelvis (72197) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0431, D0460, D4266, D7140, D7953, D9310) provided February 10, 2021 to February 26, 2021.

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed dental services are not covered under 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. 

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 dental services (D0431, D0460, D4266, D7140, D7953, D9310) provided February 10, 2021 to February 26, 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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. 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 surgical management of gangrenous cholecystitis and for new onset atrial fibrillation. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D1110, D0120) provided on February 2,
2021.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the provider is not eligible for Medicare payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental
services (D1110, D0120) provided on February 2, 2021.