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

We decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310).

You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.

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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided by an out-of-network provider.

You asked the Plan to pay for the chiropractic services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the out-of-network provider did not request authorization from the Plan. The Plan has confirmed that the services were not urgent or emergent and the enrollee was not outside of the area; therefore, there is no out-of-network exception allowed.

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 the chiropractic services provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the Computed Tomography (CT) scan of the thorax (71250).

You asked the Plan to reduce the copayment for the CT scan. You say that you paid less out-of-pocket when you had this same service. The Plan denied your request. The Plan says the copayment for this service is $110 according to your contract.

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 $110 copayment for radiological diagnostic services.

You have been asked to pay a $110 copayment for the CT scan. A CT scan falls within the radiological diagnostic 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 reduce the copayment for the Computed Tomography (CT) scan of the thorax (71250).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-transportation ambulance services.

You asked the Plan to pay for non-transportation ambulance services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit, if no transport of a Medicare enrollee occurs, then there is no Medicare-covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for non-transportation ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) and topical application of fluoride varnish (D1206).

You asked the Plan to pay for the bitewings and topical application of fluoride varnish. You say that your dentist did not realize that your insurance benefits covered the full mouth x-ray, and not the bitewing x-ray. The Plan denied your request. The Plan says these services are not covered benefits. The Plan also says that you did not elect to purchase optional supplemental dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) and topical application of fluoride varnish (D1206).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs min-max assist for functional mobility of self-care tasks. You also say that the enrollee requires inpatient rehabilitation services for medical management. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have 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 in the Rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date (99235).

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 this service is not payable as the claim was submitted untimely.

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.

The record shows that a claim for this service was not filed until October 30, 2020. 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 observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date (99235).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing.

You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered for the diagnosis billed and was performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, lab test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would prefer to see this specific doctor. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 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-approve physician services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you should not owe a copayment for a mammogram. 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 $50 copayment for X-rays.

The record shows that you received a mammogram screening on September 29, 2020. Therefore, the mammogram provided is considered diagnostic and you are responsible to pay the $50 copayment.

You have been asked to pay a $50 copayment for a diagnostic mammogram. A diagnostic mammogram 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 diagnostic mammogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power lift for a scooter.

You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power lift for a scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour diabetic test strips (A4253).

You asked the Plan to pre-approve the Contour diabetic test strips. You say that the test strips are medically necessary. The Plan denied your request. The Plan says the requested brand of test strips are not covered.

The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred.

We looked at the file and Medicare rules. The file did not include any clinical documentation to show any reason why the plan preferred brands (Accu-Check and Onetouch) would be inappropriate for the enrollee. Based on this information, we decided that Medicare rules for coverage of the Contour diabetic test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour diabetic test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.

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 the medical services by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it is the provider's responsibility to bill the primary plan or any liability insurance.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the medical services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a Magnetic Resonance Imaging (MRI)
scan of the lower extremities (73721) and a Computed Tomography (CT) scan of the abdomen and pelvis (74176).

You asked the Plan to waive the copayments for the MRI and CT scan. You say that you cannot afford the
copayment and you believe this charge is an oversight in billing. The Plan denied your request. The Plan says
diagnostic radiology services have a $225 copayment per day, per provider.

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 $225
copayment for diagnostic radiology services.

You have been asked to pay a $225 copayment for the MRI and CT scan. An MRI and a CT scan both fall
within the diagnostic radiology 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 copayments
for the MRI of the lower extremities (73721) nd the CT scan of the abdomen and pelvis (74176).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that you needed to see the dentist to determine if a crown could be attached. You also say that if you did not have this appointment, it would be the equivalent of buying a new car without test driving it. The Plan denied your request. The Plan says 1 limited oral evaluation per calendar year. The Plan also says that the frequency limit 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 frequency limit of 1 limited oral evaluation has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services.

You asked the Plan to pay for the services provided. You say that there is no visit maximum for chiropractic
services. The Plan denied your request. The Plan says the services are not covered when billed by a
chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The file shows that traction therapy, and electrical stimulation were provided. The services at issue are not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the medical
services.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the extremity study (93970).

You asked the Plan to pay for the extremity study. You say that you would like reconsideration because this service was billed according to the medically necessary indication. The Plan denied your request. The Plan says that the diagnosis code billed is not appropriate for the service rendered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 93970 is supported in the record. Specifically, the relevant Local Coverage Article does not exclude the billed diagnosis. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated, and we must find in your favor. Based on this information, we decided that Medicare rules for coverage of the extremity study have been met. Therefore, we decided that the Plan has to pay for the extremity study (93970).

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the critical care services (99291).

You asked the Plan to pay for the critical care services. You say that you would like reconsideration because this provider was acting as a critical care physician and did not perform any procedures on the member. The Plan denied your request. The Plan says that this service is considered part of the global surgery package.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99291 is supported in the record. Specifically, the services of other physicians are not included in the global surgery payment. The record indicates that this provider did not render the initial procedure and there is no evidence of a transfer of care agreement in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of the critical care services have been met. Therefore, we decided that the Plan has to pay for the critical care services (99291).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided by an out of network provider.

You asked the Plan to pay for the physician services (99337). You say that you rely on the facility to get authorization. The Plan denied your request. The Plan says you did not request 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 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 the physician services provided by an out of network provider.