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

We decided that the Plan does not have to pay for lab services (80053, 84443, 83036, 84439, 85025) provided September 2, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT code 80053, 84443, 83036, 84439, & 85025 is not supported in the medical record. Specifically, rules for payment to Rural Health Clinics and Federally Qualified Health Centers were not met. No Interim Rate Letter was received from the provider. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80053, 84443, 83036, 84439, 85025) provided September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-ray (D0220) provided on October 19, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you were given incorrect information regarding your dental coverage. The Plan denied your request. The Plan says the claim was paid correctly.
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 the services are listed as covered, the provider in this case is out of network. Out of network dentists may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-ray (D0220) provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you more for the oxygen concentrator you purchased from an out-of-network provider on August 19, 2021.
You asked the Plan to reimburse you more for the oxygen concentrator. You say that you were told that you would be reimbursed the full purchase price minus your 30% coinsurance. The Plan denied your request. The Plan says that it has reimbursed you according to the Medicare fee schedule for this item.
The Plan must follow Medicare rules. Medicare rules say that for non-contracting, non-participating Durable Medical Equipment (DME) suppliers, the Plan must pay the difference between the enrollee's cost sharing and the DME supplier's bill. The enrollee only pays plan-allowed cost sharing, which equals the coinsurance percentage multiplied by the total bill. According to the case file, you purchased this oxygen concentrator from a non-contracting, non-participating DME supplier. This means that the Plan must pay the difference between your cost sharing and the DME supplier's bill. The rule does NOT say that the Plan only pays up to the Medicare allowed rate. According to the bill, the billed amount for this item is $2615.00. You are required to pay 30% coinsurance for out-of-network DME. If you subtract the 30% coinsurance ($784.50) from the billed amount ($2615), that means that the Plan is responsible for reimbursing you the difference of $1830.50 ($2615.00- $784.50 = $1830.50). Therefore, we decided that the Plan has to reimburse you more for the oxygen concentrator you purchased from an out-of-network provider on August 19, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal injections.
You asked the Plan to pre-approve spinal injections. You say that you are in severe pain. You say that without the injections a 4-day hospital stay, and surgery will be required. The Plan denied your request. The Plan says the requested injection services are not medically necessary because the enrollee did not receive at least 80% relief of pain from previous diagnostic injections.
The Plan follows Medicare rules. Medicare rules say that RFA services are covered when medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve spinal injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records do not show that the enrollee had the required two medically reasonable and necessary diagnostic medial branch blocks (MBB) with at least 80% relief each prior undergoing an initial radiofrequency ablation (RFA). The records only showed one set of lumbar medial branch blocks (MBB) with only 50% pain relief for two days. In addition, the enrollee has a diagnosis of lumbar radiculopathy due to spinal stenosis. The review has determined that the requested RFA is not medically reasonable or necessary 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 spinal injections have not been met.
Therefore, we decided that the Plan does not have to pre-approve spinal injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewings (D0274), and an additional intraoral radiographic image (D0230) provided by a participating provider on October 4, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, prophylaxis, bitewings, and an additional intraoral radiographic image. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for the services provided has already been 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, prophylaxis, bitewings, and an additional intraoral radiographic image based on the coverage rules.
We looked at the file, and Medicare rules. Evidence was provided that shows that these services were provided on January 5, 2021, January 26, 2021, and June 15, 2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, prophylaxis, bitewings, and an additional intraoral radiographic image have already been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), bitewings (D0274), and an additional intraoral radiographic image (D0230) provided by a participating provider on October 4, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet criteria.
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 the service is medically necessary. Our physician reviewer found you do have documented skilled nursing needs, as you appear to be receiving most of your nutrition via enteral feeding. You do not have documented skilled therapy needs, as you appear to have reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.
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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs and his lungs were clear. The enrollee was at a modified independent to supervision/stand by assist level with functional mobility including gait to 223 feet with a rolling walker. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 18, 2020, to 
July 13, 2020. 
 
You asked the Plan to pay for the home health services. You say that additional claims for same service from 
same provider were paid. The Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for the home health services was not filed until November 2, 2021. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from June 18, 
2020, to July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 19, 2021.
You asked the Plan to pay for the limited exam. You say that this service was necessary and should have been covered. The Plan denied your request. The Plan says you had a previous limited oral exam provided and covered on September 23, 2021. This service is covered once per year, so the exam provided on the date in question exceeds the limitations of 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. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a frequency that exceeds what is covered under this benefit. Documentation supports that the Plan has paid for a previous limited oral exam for you in 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve skilled nursing care. You say that you need a proper and safe discharge plan, and SNF care is necessary for you to return home safely. The Plan denied your request. The Plan says the criteria for admission to an SNF are not met. You do not require daily skilled therapy. You do not have daily skilled nursing needs and you do not require daily skilled services in an inpatient setting. Your rehab and medical needs can be met with part-time skilled services in a lower level of care
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 skilled nursing care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required for you to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a multi-layer compression system; leg (below knee), including ankle and foot (29581) rendered by the out-of-network (OON) provider on April 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the application of a multi-layer compression system; leg (below knee), including ankle and foot (29581) rendered by the out-of-network (OON) provider on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc for the enrollee.
You asked the Plan to pre-approve Orthovisc. You say that this is medically necessary. The Plan denied your request. The Plan says that there is limited documentation to support that he has failed three months of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation can be covered if Medicare criteria has been met. 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 Orthovisc. Our reviewer says that Orthovisc is not considered medically reasonable and necessary in this case. Records do not document trial and failure of intra-articular corticosteroid injection therapy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Orthovisc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room (ER) visit billed for date of service February 19, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you did not go to the ER and you never saw the provider. You said that you went to get a vaccine only. The Plan denied your request. The Plan says that you were charged this copayment correctly.
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. Specifically, medical records are required to determine if the provider billed these services appropriately and if the copayment was applied correctly. The ER that billed for these services is a contract provider with the Plan. Because of this, we consider these records within the Plan's control. The Plan has failed to provide any medical records that would support the charging of this copayment. Without these records, we cannot determine if the copayment was charged correctly. the Plan must waive the copayment for the emergency room (ER) visit billed for date of service February 19, 2021. Therefore, we decided that the Plan has to waive the copayment for the emergency room (ER) visit billed for date of service February 19, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says daily therapy can be provided at a lesser 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 physician reviewer found that you were admitted to the acute care hospital with chest pain. You were treated with antibiotics for suspected pneumonia. You remain weak. You are functioning mostly at a minimal to supervision assist level. You are using a walker to ambulate and have poor endurance.
The documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may well be able to fully participate in an intensive rehabilitation therapy program, however the documentation supports that the services could be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for five crowns (D2740) and five core buildups (D2950) provided on September 30, 2021.
You asked the Plan to pay for the crowns and core buildups. You say that some portion of this claim should be covered by the Plan and still within the limits of the 2021 benefit year. The Plan denied your request. The Plan says there is a $1,000 benefit limit for all in-and-out-of-network comprehensive dental restorative services every calendar year. This benefit limit applies to restorations, endodontics, periodontics, oral surgery, crowns, dentures, partials, bridges and implants. The Plan has already paid the full $1,000 annual limit for restorative dental services for you in 2021.
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 maximum of $1,000 per calendar year for comprehensive restorative dental care. Though the Plan offers a dental benefit in excess of Medicare coverage, there is a $1,000 annual limit for dental restorations.
Documentation shows that the Plan has paid $1,000 toward dental restorations for you between March 10, 2021, and March 11, 2021. Therefore, we decided that the Plan does not have to pay for five crowns (D2740) and five core buildups (D2950) provided on September 30, 2021.