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

We decided that the Plan has to pay forthe hospital discharge day management (99238) provided on July 24, 2020.You asked the Plan to pay forthis service. You say thatyou are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says that this procedure has been billed and coveredat the maximum frequencyallowable according to the contractual policy.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, the Plan has stated that this service has been billed andallowedpreviously. However, the Plan has not provided documentation to support that this service has beenpreviously paid. Therefore, we decided that the Plan has to pay forthe hospital discharge day management (99238) provided on July 24, 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 toopen the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services provided a participating provider on September 21, 2020.You asked the Plan to waive the copayment for physician services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has 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). Your contract with the Plan clearly says that you must pay a $45 copayment for physician/practitioner services/specialist. You have been asked to pay a $45 copayment for physician services. Since physician services were provided, the correct copayment has been applied. Physician services falls within the physician/practitioner services/specialist 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 physician services provided by a participating provider on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dermatology services provided from June 25, 2020, to August 18, 2020 by an out of network provider.You asked the Plan to pay forthe dermatology services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not obtain 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 services at issue in this appeal. The Plan did not pre-approve the serviceat 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 forthe dermatology services provided from June 25, 2020, to August 18, 2020 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria that requires a high level of physician supervision in combination with therapy services in an inpatient setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. Ourreviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee 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-approveacute IRF admission and services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the apolipoprotein testing rendered on September 3, 2020. You asked the Plan to pay for these services. You say that you should not be liable. The Plan denied your request. The Plan says that the services are not covered. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the apolipoprotein testing rendered on September 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided.

You asked the Plan to pay for the physician service. You say that you did not receive proper notice of the enrollee's benefit determination. You say that you depend on the facility for timely notice of the enrollee's health insurance coverage. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the claim was received more than 12 months after the date of service in this case.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after Jan., must be filed no later than one calendar year after the date of service.

The record shows that a claim for the physician service was not filed. 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 psychiatric diagnostic evaluation provided
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three alveoloplasties in conjunction with extractions (D7310 x3).

You asked the Plan to pre-approve the alveoloplasties. You say that you need these services.The Plan denied your request. The Plan says this 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 pre-approve three alveoloplasties in conjunction with extractions (D7310 x3)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retainer crown (D6750) and the pontic (D6240) provided on September 17, 2020.You asked the Plan to pay forthe dental services. You say that you went to the doctor for tooth pain. You say that you were advised you would need a crown and a root canal. You say that you could not afford both so the dentist said they would do the root canal at no charge. You also say that you are upset that the dentist said you would not have to pay for the root canal and then charged you anyways.The Plan denied your request. The Plan says there is a 50% coinsurance for prosthodontic services.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 prosthodontics are listed as covered services, there is a 50% coinsurance for prosthodontic services and prosthodontic maintenance that you received in network.Therefore, we decided that the Plan does not have to pay forthe retainer crown (D6750) and the pontic (D6240) provided on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on August 19, 2020.You asked the Plan to waive the copayment forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for outpatient surgery or procedure. Review of the file shows that you received outpatient surgery on August 19, 2020. You have been asked to pay a $250 copayment for these services. These services fall within the outpatient surgery or procedure 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 obligationyou agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient surgical services rendered on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the cataract surgery (66984) provided on July 20, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $200 copay per day for each Medicare-covered surgery performed in an ambulatory surgical center.You have been asked to pay a $200 copayment for theMedicare-covered surgery providedat an ambulatory surgical center. 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 copaymentfor the cataract surgery (66984) provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services (80053, 85025, 36415, 86140, 85652) provided on August 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON laboratory services. You say that you should not be penalized because the order physician failed to obtain authorization.The Plan denied your request. The Plan says these services were not authorized.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 forthe laboratory services (80053, 85025, 36415, 86140, 85652) provided on August 7, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodontal scaling and root planing (D4341) provided on October 1, 2020.You asked the Plan to reimburse you forthe dental services. You say that you did not ask for any type of special cleaning or x-rays. You say that you paid for the services upfront with the belief that you would be reimbursed by your plan. You say that you were under the impression that the cleaning would be covered under your policy with no copayment. You say that you did not realized that what you asked for and what was provided were not the same. You also say that you feel that you were misled by the dentist and your plan.The Plan denied your request. The Plan says they confirmed with the provider that you signed a treatment plan which included a deep cleaning. The Plan says that a deep cleaning for each quadrant has a copayment of $80. The Plan also says that the claim processed 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 periodontal maintenance is listed as a covered service, there is an $80 copayment for each quadrant that this service is performed.Therefore, we decided that the Plan does not have to reimburse you forthe periodontal scaling and root planing (D4341) provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve K0108 push handles for a power mobility device. You asked the Plan to pre-approve push handles. You say that the claim should be paid. The Plan denied your request. The Plan says the push handles do not serve a medical purpose. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve K0108 push handles for a power mobility device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 lab work provided on January 30, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe injection rendered on June 18, 2020.You asked the Plan to waive the coinsurance forthese services. You say that you never had to pay before.The Plan denied your request. The Plan says the coinsurance was 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. Review of the file shows that you received an injection of denosumab on June 18, 2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B non-chemotherapy prescription drugs 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 coinsurance forthe injection rendered on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services (97803) provided on July 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for medical nutrition therapy services. You say that you were not aware your insurance did not cover this and did not know you needed a referral to see a nutritionist prior to setting up an appointment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 medical nutrition therapy services (97803) provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tertiary level referral for a pulmonary function test.You asked the Planto pre-approvethe referral. You say that thisis medically necessary.The Plandenied your request. The Plansaysthe notes do not show a need for a higher level of care.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found standard pulmonary function testing can reasonably be done in a local pulmonary function testing facility. The records do not provide any justification for such a referral. They do not even mention pulmonary function testing. The most recent clinical note is from February 2019.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 referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tertiary level referral for a pulmonary function test.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services rendered on October 1, 2020.You asked the Plan to waive the copayment forthese services. You say that the services were rendered as part of an office visit.The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered laboratory tests. Review of the file shows that you received laboratory services rendered on October 1, 2020. These services are separate from the office visit services. You have been asked to pay a $10 copayment for these services. These services fall within the Medicare-covered laboratory tests 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 forthe laboratory services rendered on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were 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 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 forthe medical services provided on September 22, 2020 by an out of network (OON) provider.