Persius/hicric huggingface dataset:
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 it is unsafe to discharge the enrollee home. The Plan
denied your request. The Plan says that the enrollee can safely receive the services he 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 chest pain and had
coronary artery bypass grafting. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings identified with code A6549 that were issued on October 15, 2021.

You asked the Plan to pay for compression stockings. You say that the items at issue are a medical necessity for the enrollee. The Plan denied your request. The Plan says the items at issue are not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for compression stockings identified with code A6549 that were issued on October 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of extremity veins provided on August 24, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you feel that the Plan should cover all or some of the allowed amount for the ultrasound. 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 $155 copayment for radiological diagnostic services, not including X-rays. You have been asked to pay $93.57, which is less than the $155 copayment for the ultrasound. The ultrasound 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 ultrasound of extremity veins provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient visit provided on August 9,
2021.
You asked the Plan to waive the deductible for an outpatient visit. You say that you went to an office visit for a
physical. The Plan denied your request. The Plan says the proper deductible was 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). Your contract with the Plan clearly says that you must pay a $147
deductible for combined in-network and out-of-network medical deductible. Prior to August 9, 2021, there was
a total of $14.14 paid towards the deductible of $147 leaving a balance of $132.86 ($147 total deductible -
$14.14 paid towards deductible). The total amount allowed for the date of service was $87.48. Since the
deductible was not paid prior to the date of service the $87.48 was charged towards the $132.86 balance on the
deductible.
You have been asked to pay a $87.48 deductible for an outpatient visit. The deductible falls within the What is
your plan deductible 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 deductible for an outpatient visit
provided on August 9, 2021.
Your complaint about your experience with this provider 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 19, 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 were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care visit coded 99291 provided on January 14,
2021.
You asked the Plan to pay for the critical care visit. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted
did not include the time spent providing the critical care services. This means that the documentation did not
support a critical care visit of 30-74 minutes was performed. Based on this information, we decided that
Medicare rules for coverage of the critical care visit have not been met. Therefore, we decided that the Plan
does not have to pay for the critical care visit coded 99291 provided on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on September 9, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you expected the office to contact the insurance plan to have the procedures they wanted to perform pre-approved. The Plan denied your request. The Plan says these services exceed the frequency limitations in your benefit 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on September 23, 2020 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a pulp vitality test (D0460) provided by a participating provider on September 22, 2021.

You asked the Plan to pay for a limited oral evaluation and a pulp vitality test. You say that you had to go to another dentist because you needed a root canal. The Plan denied your request. The Plan says the benefit limit of D0140 has already been exhausted. The Plan says that D0460 is not a covered 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 D0460 is not among those covered under this benefit. Evidence was provided that show D0140 was provided on September 14, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a pulp vitality test (D0460) provided by a participating provider on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) for tooth # 2 provided on March 4, 2021.

You asked the Plan to pay for the crown. You say that you thought 2 crowns were covered. The Plan denied your request. The Plan says 1 porcelain crown is covered per calendar year. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and porcelain crown is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a porcelain crown that you received on June 10, 2021. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) for tooth # 2 provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on September 11, 2021.
You asked the Plan to pay for the eye refraction. You say that this service should be covered. The Plan denied
your request. The Plan says this eye refraction was performed as part of a medical (non-routine) eye exam and
was not performed by a provider in the Plan's routine vision network. Medicare does not cover eye refractions,
and the Plan's rules for coverage of this service have not been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are received from a provider in the Plan's specified routine
vision network as part of a routine vision exam.
We looked at the file and the Plan's rules. The record indicates that the eye exam provided on the date in
question was performed for medical purposes and was not a routine eye exam. The provider in this case is also
not part of the Plan's routine vision network. Based on this information, we decided that the Plan's rules for
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for
the eye refraction (92015) provided on September 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on August 13, 2021.

You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.

We find that CPT code R0070 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) indicator of 3. The documentation does not support that the enrollee was in a skilled nursing facility. This means this code was billed with an incorrect place of service. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (97014) provided August 23, 2021 to September 16, 2021.

You asked the Plan to pay for the chiropractic service. You say that the decompression process relieved the pressure on the discs and nerves and compared to the cost of back surgery is a bargain and should be covered. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation (97014) provided August 23, 2021 to September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 7, 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 separately payable.

The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 

We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral x-rays (D0210) provided by a participating provider on May 28, 2021.
You asked the Plan to pay for a comprehensive oral evaluation and intraoral x-rays. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0150 and D0210 was previously exhausted.
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 a comprehensive oral evaluation and intraoral x-rays once every 36 months.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and intraoral x-rays have already been exhausted. Evidence was
provided to show that D0150 and D0210 was provided on December 31, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral x-rays (D0210) provided by a participating provider on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Evenity (J3111) provided on September 28, 2021.

You asked the Plan to pay for Evenity. You say that this was billed correctly. The Plan denied your request. The Plan says this is not supported.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The submitted medical records do not include documentation of the enrollee's condition to indicate these services were necessary. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pay for Evenity (J3111) provided on September 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer for the enrollee.
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the
preferred products.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Injectafer. Our reviewer says that
Injectafer is not medically reasonable and necessary. The Plan requires a trial of Ferrlecit, Sodium Ferric
Gluconate, Infed, or Venofer before they will approve Injectafer. In this case, the patient has not tried and
failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would
likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet step therapy criteria for Injectafer.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from September 20, 2021, to September 23, 2021.

You asked the Plan to waive the copayment for emergency care. You say that the services were medically necessary and you should not be held responsible for the charges. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided from September 20, 2021, to September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 16, 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 all care with non-contracted providers requires prior 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 laboratory services provided to the enrollee on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) manual therapy techniques (97140) electrical stimulation (G0283) provided August 5, 2021.

You asked the Plan to pay for the chiropractic services. You say that you are appealing non-payment of services. Please see all records attached. The Plan denied your request. The Plan says this service is not covered when billed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) manual therapy techniques (97140) electrical stimulation (G0283) provided August 5, 2021.