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

We decided that the Plan does not have to pay forthe core buildup, including any pins when required, provided on November 19, 2019.You asked the Plan to pay forthe core buildup. You say that if you did not have the work done you would have had to have the tooth extracted.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 pay forthe core buildup, including any pins when required, provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe laboratory work provided on November 13, 2019.You asked the Plan to waive the coinsurance forthe laboratory work. You say that you believe the metabolic panel should be 100% covered under the wellness exam. 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 10% of the cost for Medicare-covered laboratory test. You have been asked to pay a total of $23.07 which is 10% of the total allowed amount for the laboratory work. The allowed amount is $230.64. ($230.64 x 10% = $23.07). The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decipher prostate cancer classifier assay provided on July 24, 2019.You asked the Plan to pay forthe Decipher assay. You say that this should be covered for this enrollee to determine the best treatment strategy.The Plan denied your request. The Plan says the criteria for this testing were not met.The Plan must follow Medicare rules. Medicare rules say that Decipher testing is covered for prostate cancer patients deemedhigh risk, post-prostatectomy, in order to decide whether to provide radiation therapy. It may also be covered for those with low or very low risk in order to determine whether definitive treatment or active surveillance is necessary.In this case, the enrollee has not had a prostatectomy which means coverage rules under LCD L36343 are not met. In addition, the enrollee is noted to have unfavorable intermediate risk cancer, Gleason score of 7. The testing is not being used to decide between definitive treatment and active surveillance, as radiation is already planned. As such, the criteria under LCD L37818 are also not met.Therefore, we decided that the Plan does not have to pay forthe Decipher prostate cancer classifier assay provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (92015) on March 8, 2019 You asked the Plan to pay for refraction services. You say that as a member in good standing, you are not responsible for the oversite of the provider's office to request prior approval for this treatment.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover for refraction services.We looked at the file and the Plan's rules. Refraction is not a covered benefit Based on this information, we decided that the Plan's rules for coverage of refraction services have not been met.Therefore, we decided that the Plan does not have to pay for refraction services (92015) on March 8, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that your providers have recommended home care and you will not need daily physical therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services arenot necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
You asked the Plan to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer is experimental. More research is needed to show it is safe and effective before it can be considered medically necessary. 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 insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora Computed Tomography (CT) scan provided on October 25, 2019.You asked the Plan to waive the copayment for CT scan. You say that you believe it is outrageous for the Plan to pay a small amount of this claim and hold you responsible for this amount.The Plan denied your request. The Plan says the copayment amount 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). Your contract with the Plan clearly says that you must pay $175 copayment for CT scan performed by a provider other than your primary care provider. You have been asked to pay $175 copayment for CT scan. CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 Computed Tomography (CT) scan provided on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that you feel that IRF care would be the best option for recovery.The Plandenied your request. The Plansaysthe documentation shows you are medically stable and does not indicate that you require three hours of daily therapy.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 reasonableand necessary based on Medicare guidelines. Our physician reviewer found the enrollee has a history of knee replacement and was admitted due to a peri-prosthetic infection, undergoing exploratory surgery with antibiotic spacer placement. The recent records indicate the enrollee is tolerating antibiotics and is non-toxic. She is able to make needs known, and labs are stable.Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician oversight in the hospital setting. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly MIN assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injection provided on March 13, 2019.
You asked the Plan to waive the copayment for the spinal injection. You say that when you were enrolled in a different health plan you did not have a copayment for this service. You say you would like the copayment waived. 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 a $350 copayment for outpatient hospital services at an in-network outpatient hospital. You have been asked to pay a $350 copayment for the spinal injection. The spinal injection falls within the "Outpatient hospital services" 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 spinal injection provided on March 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on  June 13, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing serivces. You say that you would like this claim reprocessed.The Plan denied your request. The Plan says no prior authorization was 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 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 skilled nursing services provided on  June 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain crowns (D2740) for teeth # 6 and 11 provided on September 25, 2019.You asked the Plan to pay forthe dental services. You say that the agent did not explain that your dental rider had a yearly limit of $1,000. You say that you had to get 6 crowns. You say that you received a new member card but you did not receive any other written information. You also say that the Plan should cover all 6 crowns at the 50% benefit rate.ThePlan denied your request. The Plan says there is an annual maximum of $1,000. The Plan says that the annual maximum benefit has been exhausted.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverageand crowns are a covered service, the annual maximum benefit of $1,000 per year has been exhausted. Therecord shows that you received a 2019 Evidence of Coverage which states the annual maximum for the Platinum Dental Rider.Therefore, we decided that the Plan does not have to pay forthe porcelain crowns (D2740) for teeth # 6 and 11 provided on September 25, 2019.Your complaint about being misinformed by the agentis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these typesof complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing rendered to the enrollee on October 22, 2019.
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that DecisionDx-Melanoma testing is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee has a T4b tumor and had not had a sentinel lymph node biopsy. 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 DecisionDx-Melanoma testing rendered to the enrollee on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 9, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service 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 laboratory services provided on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injection provided on December 4, 2018.
You asked the Plan to waive the coinsurance for the injection. You say that you were told the services would be covered less your copayment. The Plan denied your request. The Plan says that the coinsurance 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 each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare-covered Part B drug 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 for the Botox injection provided on December 4, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 7, 2019 to enrollee 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 a non-participating 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 areaurgent 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 forthe medical services provided on November 7, 2019 to enrollee by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for the enrollee's approved procedure.
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says the enrollee has no comorbidities that would justify an inpatient admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 an inpatient admission. Our physician reviewer found that there is no documentation to support the need for an inpatient admission for the procedure. The services should be able to be performed as an outpatient, unless there are circumstances documented that would require inpatient status. There is no documentation that would support inpatient status justification. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for the enrollee's approved procedure.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly minimal assist for functional transfers and a longer duration of therapy can allow for meaningful gains to be attained within a reasonable period. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 1, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you were never advised you had a copayment.The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.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 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to the enrollee on October 17, 2019.
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 procedure code G0480 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0480 is definitive drug testing, 1-7 drug classes. We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation indicates only drug screening was requested with no documentation to indicate that definitive drug testing was ordered. 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 definitive drug testing rendered to the enrollee on October 17, 2019.