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

We decided that the Plan does not have to pay for targeted genomic sequence analysis provided to the enrollee on October 29, 2019.You asked the Plan to pay for the testing. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim at issue should not be adjusted.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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with ovarian cancer. Testing specifically related to her ovarian cancer, and for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to ovarian cancer or for whichthere are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the provided panel testing was medically necessary or reasonable.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pay fortargeted genomic sequence analysis provided to the enrollee on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe acute inpatient rehabilitation facility (IRF) care to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe IRF care. You say that you would like your mother to go to this facility.The Plan denied your request. The Plan says that these services can be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Planhas to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe acute inpatient rehabilitation facility (IRF) care to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveporcelain crowns on teeth 23, 24, 25, 26, 29, 30 (D2750) core buildup, teeth 29, 30 (D2950).You asked the Plan to pre-approvethe dental services. You say that you are appealing the denial for multiple teeth crowns. Your bill is $10, 000 and you are wondering what is the Plan going to pay.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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. Dental services must be rendered by a participating dentist.Therefore, we decided that the Plan does not have to pre-approveporcelain crownson teeth 23, 24, 25, 26, 29, 30 (D2750) core buildup, teeth 29, 30 (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology rendered on January 17, 2020.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 claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. There is no documentation to support the use of the -77 modifier.Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the cytopathology rendered on January 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.You asked the Plan to pre-approve a sleep study. The Plan denied your request. The Plan says a sleep study is not medically necessary.The Plan follows Medicare rules. Medicare rules say that sleep studies are covered for the above conditions.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 a sleep study. Our reviewer says that the requested sleep study is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee in this case is a 51-year-old female with diagnosed primary insomnia and insomnia due to mental condition. According to the provided records, there was no important screening criteria for sleep apne a or narcolepsy present to show support for a sleep study. There was no evidence of uncontrolled hypertension, episodes of gasping for air, severe snoring, or sudden falling asleep during the daytime. The diagnoses provided suggested a primary psychological aspect to the insomnia which would not alone justify a sleep study.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sleep study have not been met.Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fordiagnostic digital breast tomosynthesis(77062) provided on February 12, 2020.You asked the Plan to pay forthe diagnostic digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code 77062 has a status code of I which is not valid for Medicare purposes.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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay fordiagnostic digital breast tomosynthesis (77062) provided on February 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 25, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the health plan paid nothing of the $74.07 and you would like to appeal. 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 up to a maximum of a $90 copayment for emergency care. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for the emergency room visit.
You have been asked to pay a $74.0 copayment for the emergency room visit. The emergency room visit 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 the emergency room visit provided on December 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 2, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan
covers care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for laboratory services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on February 25, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you were told that you would not owe cost-sharing charges when you signed up with the Plan.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 $40 copayment for specialist services. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amountbased 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 fora specialist visit provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 13, 2019.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the outpatient testing services. You say that you would like reconsideration
because the services rendered were medically reasonable and necessary. The Plan denied your request. The
Plan says there were no circumstances that would allow for an exception to cover the services received from an
out-of-network provider while the enrollee was on an HMO plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 has network providers
available who can provide 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 the medical services provided on March 5, 2019
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build-ups and gingivectomies for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that these services are not covered.Medicare generally does not cover dental services. However, thePlan 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-approvecore build-ups and gingivectomies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear and vision services provided on March 9, 2020 by an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that ever since you had insurance the Plan has always paid the bill. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Review of the file show that you received the eyewear and vision services on March 9, 2020 provided by an out-of-network provider. Your EOC states, the Plan will cover more vision care than what Medicare covers, but you must use a doctor in the Plan's vision network. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the eyewear and vision services provided on March 9, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that a shower chair is necessary because it is a
taxing effort to move around. You say that you are afraid of losing your balance and falling. You say that you
have no one to assist with activities of daily living. The Plan denied your request. The Plan says a shower chair
is considered a convenience item and is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to make an additional payment of $1,000forthe complete mandibular denture and extractions. We decided that the Plan does not have to pay the full amount for the complete mandibular denture and extractions. You asked the Plan to pay the full amount for the complete mandibular denture and extractions. You say that you do not understand how you can be denied at the beginning of the physical year of your dental insurance.The Plan says that you have a $1,000 combined allowance for supplemental preventive and comprehensive services every year. The Plan also says that your $1,000 dental benefit allowance was reached, and the claim was partially paid up to your benefit allowance.We decided that the Plan has to make an additional payment of $1,000forthe complete mandibular denture and extractions.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 complete mandibular denture and extractions up to the $2,000 combined allowance per year. Once the $2,000 has been exhausted, you are responsible for any amount over and above the allowance amount. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for additional coverage of the complete mandibular denture and extractions have been met.Therefore, we decided that the Plan has to make an additional payment of $1,000forthe complete mandibular denture and extractions. We also decided that the Plan does not have to pay the full amount for the complete mandibular denture and extractions.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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. We have told the Plan that they are responsible for paying an additional $1,000 for these services, which will exhaust your annual maximum benefit. You are responsible for the remaining balance.Therefore, we decided that the Plan does not have to pay more than the additional $1,000forthe complete mandibular denture and extractions.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 pre-approve cone beam CT scan(D0365) facial surgery, repair of
maxillofacial soft- and hard-tissue defect (D7955) sinus augmentation (D7951).
You asked the Plan to pre-approve the dental services. You say that you are requesting reversing of the
decision to not cover the enrollees facial and sinus surgery so that her dental implants can be placed. The Plan
denied your request. The Plan says these services are not covered under the plan 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. Services not listed under the
Description of Benefits is not covered by the plan.
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 cone
beam CT scan(D0365) facial surgery, repair of maxillofacial soft- and hard-tissue defect (D7955) sinus
augmentation (D7951).
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 IRF admission is not medically necessary.
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. 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. While the enrollee may benefit and participate in multiple therapies her functional level does not require this on an 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional intraoral periapical x-ray and resin-based composites provided on January 22, 2020 and January 28, 2020.You asked the Plan to pay forthe additional intraoral periapical x-ray and resin-based composites. You say that you asked the provider's office when you were going to receive the crown and were advised it was already done. You also say that you do not believe you received the crown.The Plan denied your request. The Plan says the benefits for these services have been satisfied and the frequency limitations have been exceeded.Medicare generally does not cover dental services. However, thePlan 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, intraoral x-rays are limited to one procedure per calendaryear. The record shows that you received a first intraoral periapical x-ray on January 22, 2020 and your intraoral x-rays benefit was then exhausted. The Plan contract also says that restorations are limited to two procedures per calendar year. The recordshows that you received three resin-based composites on January 28, 2020, two of which were paid at the in network rate by the Plan, and your restorations benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe additional intraoral periapical x-ray and resin-based composites provided on January 22, 2020 and January 28, 2020.