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

We decided that the Plan has to pay for the therapy services provided on October 20, 2020, through November
18, 2020.

You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that CPT code G0153 was not billed with the
appropriate revenue code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the therapy services have been met. Specifically, the therapy codes on this claim have been billed
with the appropriate revenue codes. Therefore, we decided that the Plan has to pay for the therapy services
provided on October 20, 2020, through November 18, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational
therapist on December 17, 2019.

You asked the Plan to pay for occupational therapy services. You say that the Plan is required to pay non-contracted
providers at the preferred rate if the services are not available from preferred providers. You say that
the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request.
The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services
incident to a physician/non-physician practitioner's service must meet all incident requirements.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of occupational therapy services have not been met. Specifically, the billing provider is a nurse
practitioner. As such, OT services cannot be paid incident to this provider's professional services. Therefore,
we decided that the Plan does not have to pay for occupational therapy services provided by an occupational
therapist on December 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on February 26, 2021, to March 2, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee received a bill three months after the inpatient hospital care and the Plan did not cover the full amount. You also say that you are questioning how this claim was processed and how your mother was billed for the inpatient hospital care. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $325 copayment per day, for days 1-5 for inpatient hospital care. The enrollee's contract with the Plan also clearly says that enrollees pay a $0 copayment per day, for days 6 to discharge, for inpatient hospital care.

The enrollee has been asked to pay a $325 copayment per day for inpatient hospital care. The records show that the enrollee received inpatient hospital care for four days, resulting in a total cost share of $1,300 ($325 x 4 days = $1,300). The EOC confirms $325 is the required copayment per day for this service. 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 inpatient hospital care provided on February 26, 2021, to March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214) provided on April 28, 2021.

You asked the Plan to waive the copayment for an office visit. You say that this visit should be covered because the enrollee had a cataract surgery that did not go well and caused his retina to detach which needed another surgery. The Plan denied your request. The Plan says the visit was rendered outside the 90-day global period after a procedure and the copayment the enrollee is being charged is correct.

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 $45 copayment for physician/practitioner services, including doctor's office visits with a specialist.

The enrollee has been asked to pay a $45 copayment for an office visit with a specialist. The EOC confirms that $45 is the required copayment for this visit. An office visit with a specialist falls within the physician/practitioner services, including doctor's office visits 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 an office visit with a specialist (99214) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns - porcelain/ceramic substrate (D2740) and unspecified preventative procedure, by report (D1999) provided January 20, 2021.

You asked the Plan to pay for the crowns and unspecified preventative procedure. You say that you would like the Plan to continue to cover the services. The Plan denied your request. The Plan says the provider has opted out of Medicare and therefore the services are not covered under your benefits.

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 crowns and unspecified preventative procedure when you see any licensed 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 the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the crowns and unspecified preventative procedure have not been met. Therefore, we decided that the Plan does not have to pay for the crowns - porcelain/ceramic substrate (D2740) and unspecified preventative procedure, by report (D1999) provided January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery, biologic materials to aid in soft and osseous tissue regeneration, guided tissue regeneration, extraction and bone replacement graft provided by on May 13, 2021.

You asked the Plan to pay for the osseous surgery, biologic materials to aid in soft and osseous tissue regeneration, guided tissue regeneration, extraction and bone replacement graft. You say that you needed this done and this was incorrectly filed. You say that you paid $9,800 and more than $112 should be paid. The Plan denied your request. The Plan says the services are not covered benefits.

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 osseous surgery, biologic materials to aid in soft and osseous tissue regeneration, guided tissue regeneration, extraction and bone replacement graft provided by on May 13, 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.
You asked the Plan to pre-approve IRF care. You say that it is crucial for you to receive IRF care to gain strength, endurance, and independence. The Plan denied your request. The Plan says criteria for admission to an IRF is not met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services provided on April 27, 2021 in a Federally-Qualified Health Center (FQHC), billed with codes G0470 and 90832.

You asked the Plan to pay for the FQHC mental health services. You say that this was a medically necessary service and should be paid. The Plan denied your request. The Plan says that services of psychologists are only payable when they have documented a consultation with the enrollee's primary care physician. There is no documentation of this in the medical record.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided an applicable denial rationale for the services at issue. The rule regarding a required consultation applies to services rendered and billed by a clinical psychologist or clinical social worker. The services at issue in this case, however, were rendered and billed by a FQHC. We find that the documentation supports that these services were correctly reported on the FQHC claim, and medical records support that the services were rendered. There is no argument provided to support non-payment for the FQHC services. Therefore, we decided that the Plan has to pay for the psychotherapy services provided on April 27, 2021 in a Federally-Qualified Health Center (FQHC), billed with codes G0470 and 90832.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on June 9, 2021.

You asked the Plan to pay for the limited exam. You say that this service was covered when you had it previously. You feel you should not be responsible for these charges because you believed you were having a regular exam and did not know that there was a difference in exams or that it would not be covered this time. The Plan denied your request. The Plan says you had a previous limited oral exam in April 2021 which was covered by the Plan. This service is limited to one procedure per plan year. Therefore, the second limited oral evaluation, which was provided on June 9, 2021, is denied.

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. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

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 the services. Our reviewer says that the requested continuation of services is not medically reasonable or necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 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 continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided on April 2, 2021, to April 16, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was in the hospital continuously from March 29, 2021, until April 16, 2021. They were moved to another floor on April 2, 2021 and received two separate bills. You feel this was a billing error as there should only be one copayment for this admission. The Plan denied your request. The Plan says the inpatient care copayment applies each time the enrollee is admitted. This includes when transferring between levels of care. These copayments were applied correctly.

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 $350 copayment for each of the first five days of an inpatient hospital admission/stay. There is a $0 copay for additional days. Inpatient hospital care includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. The inpatient hospital cost sharing will apply each time you are admitted. This includes when transferring from one facility to another or within the same facility between levels of care.

The enrollee has been asked to pay a $1,750 copayment for the inpatient care ($350 x 5 = $1,750). Documentation shows that the enrollee was admitted to the acute inpatient level of care at the hospital on March 29, 2021. On April 2, 2021, they were transferred to the acute inpatient rehabilitation level at the same hospital. This is considered a transfer within the same facility between different levels of care. Therefore, the second inpatient copayment applies. 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 the inpatient rehabilitation admission and services provided on April 2, 2021, to April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site (D4266), bone replacement graft for ridge preservation - per site (D7953), collection and application of autologous blood concentrate product (D7921) provided January 5, 2021.

You asked the Plan to pay for the guided tissue regeneration, bone replacement graft and collection and application of autologous blood concentrate product. You say that you would like these services covered. The Plan denied your request. The Plan says you do not have dental coverage through the Plan.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site (D4266), bone replacement graft for ridge preservation - per site (D7953), collection and application of autologous blood concentrate product (D7921) provided January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on June 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for subsequent nursing facility care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 subsequent nursing facility care (99308) provided on June 1, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator rental charge for date of service March 25, 2021.
You asked the Plan to pay for the oxygen concentrator rental. You say that this should be paid as you are in-network with the Plan. The Plan denied your request. The Plan says the enrollee was under the Medicare hospice election on the date of service. This claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator rental charge for date of service March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) provided on July 8, 2021.

You asked the Plan to pay for the surgical placement of implant body (D6010). You say that the brochure states a full comprehensive plan which should cover all services. You say that you wouldn't have gotten it if the brochure said implants weren't covered. The Plan denied your request. The Plan says the service 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, 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 surgical placement of implant body (D6010) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit and related services (99214, 31575, J3301) provided May 11, 2021, to May 25, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for office visit and related services. You say that you believe that you should be reimbursed for the care you received. The Plan denied your request. The Plan says no payment can be made to a provider who has opted out of Medicare.
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 office visit and related services (99214, 31575, J3301) provided May 11, 2021, to May 25, 2021, by a provider who has opted out of Medicare.