Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays
(D0274), intraoral x-ray (D0220) and cleaning (D1110) provided on November 30, 2019, and the
comprehensive oral evaluation (D0150), bitewing x-rays (D0274) and two resin-based fillings (D2330, D2331)
provided on January 30, 2020.

You asked the Plan to pay for the dental services. You say that you were told this provider accepted your
insurance and the services would be covered. You also say that you cannot control when the provider submits
their claims, and you had issues with previous payments to this provider and the manner in which they were
requested. The Plan denied your request. The Plan says that the claim for dental services provided on
November 30, 2019, was filed past the allowed 12-month timeframe. In addition, dental services are not
covered when they are received out-of-network. The Plan tried reaching out to you by phone but was unable to
get clarification regarding previous payments you mentioned. These claims have been denied correctly, and the
Plan has indicated that they are investigating your concerns in a separate case.

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. 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 record shows that a claim for the dental services provided on November 30, 2019, was not filed until
January 19, 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 comprehensive oral evaluation
(D0150), bitewing x-rays (D0274), intraoral x-ray (D0220) and cleaning (D1110) provided on November 30,
2019.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274) and two resin-based fillings
(D2330, D2331) provided on January 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says conservative treatment including a steroid injection and therapy have not been completed.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. True/significant mechanical symptoms are not demonstrated on the exams provided for review. The requested procedure is not supported without failure of conservative measures (without evidence of mechanical locking). There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve knee surgery for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the spinal canal with and without contrast for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary for low back pain. The Plan denied your request. The Plan says the reason for ordering this exam with and without contract is not clear.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the denial of contrast administration to a patient with GFR of 31 is reasonable especially since MRI of the lumbar spine without contrast has not been done. The source of the enrollee's leukocytosis and back pain may be unrelated to the lumbar spine and perhaps related to a urinary tract infection. Nonetheless, without compelling reason to administer IV contrast to a patient at risk for nephrogenic systemic sclerosis, the request is not medically reasonable and prudent at this point. If the already approved MRI of the lumbar spine without contrast does not provide the desired information, a nephrology consult should be obtained prior to a contrast injection with Gadolinium. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the spinal canal with and without contrast for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the lumbar spine (72148) rendered by the out of network (OON) provider on February 4, 2020.
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 magnetic resonance imaging (MRI) of the lumbar spine (72148) rendered by the out of network (OON) provider on February 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on November 9, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 ambulance services provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transplant transportation and lodging provided from January 4, 2021, to February 5, 2021.
You asked the Plan to pay for the services provided. You say that a number of trips were made from one city to another city. The Plan denied your request. The Plan says the claim did not meet the minimum mileage of 75 miles.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
We looked at the file and the rules. The records show that the distance between the transplant hospital and the enrollee's home was less than 75 miles. Based on this information, the rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the transplant transportation and lodging provided from January 4, 2021, to February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit provided on January 27, 2021.
You asked the Plan to waive the copayment for a telehealth visit. You say that you should owe a $0 copayment for telehealth visits. 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 $20 copayment for telehealth visits. You have been asked to pay a $20 copayment for a telehealth visit. A telehealth 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 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 a telehealth visit provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. The Plan did not pre-approve the services at 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 for the services provided by an out-of-network provider on December 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided on January 21, 2021.
You asked the Plan to waive the deductible for outpatient rehabilitation services. You say that you were told that the services would be covered 100%. 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. Your contract with the Plan says that there is a $750 deductible for outpatient rehabilitation services. You received outpatient rehabilitation services on January 21, 2021. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $123.10. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not
been met at the time outpatient rehabilitation services was received on January 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 17, 2021.
You asked the Plan to pay for the non-covered dental services under medical. You say that these services should be considered under your medical benefit. The Plan denied your request. The Plan says the procedures cannot be considered as a medical 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. The Plan paid the $500 allowance. Therefore, we decided that the Plan does not have to pay for the non-covered dental services provided on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you are in a short-term facility and need
to be transferred to the LTACH in order to continue your care. The Plan denied your request. The Plan says the
guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee needs to stay in the
hospital, as he is not medically stable due to an unresponsive neurological status.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation indicates that there is no indication for admission to a LTACH.
The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require
services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care
setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on December 10, 2020.

You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). The Plan denied your request. The Plan says that the ambulance services are not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.

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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425). Our reviewer says that the ambulance service is necessary. Our physician reviewer found that the enrollee ingested an excess of laxative and was having uncontrolled diarrhea as well as abdominal pain. Upon arrival, paramedical noted blood pressure greater than 180/100 and heart rate in excess of 120. A prudent layperson would believe that the onset of acute abdominal pain following excessive ingestion of a medicinal substance could place her health in serious jeopardy. The elements of the coverage criteria are satisfied. The requested service is recommended.

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 ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) have been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on December 10, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have a pharmacy benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on November 30, 2020.

You asked the Plan to pay for the services provided. You say that coding verified the service was supported. The Plan denied your request. The Plan says there is a lack of medical documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 77331 is not supported. The file shows that the Plan requested medical records on multiple occasions. However, none were obtained. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite provided on February 10, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite. You say that you would like these services to be covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation and first intraoral periapical x-ray are not covered. The Plan also says that your benefits for restorations have been satisfied and the frequency limitation has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the problem focused limited oral evaluation and first intraoral periapical x-ray are not among those covered under this benefit. The contract also says that restorations are limited to two procedure codes per calendar year. The record shows that you received three resin-based composites on February 10, 2021, two of which were covered at the out-of-network benefit rate by the Plan, and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on February 8, 2021.
You asked the Plan to pay for the core buildup. You say that you believe it is incorrect information to say a crown is covered, but not inform you that there is a copay or other charge. The Plan denied your request. The Plan says this service is not covered.
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 core buildup, including any pins when required provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Invitae Hyperparathyroidism Panel provided on November 19, 2020.
You asked the Plan to pay for the testing services. You say that the testing clarifies disease risk. The Plan denied your request. The Plan says the services is experimental.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. In this case, there are insufficient medical records to show that the ordered testing clearly correlates with given interventions. The testing was requested for screening purposes to identify disease risk. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the Invitae Hyperparathyroidism Panel provided on November 19, 2020.