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

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services are readily available from participating providers.
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 has network providers available who can provide 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 medical services provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT provided on July 20, 2020.
You asked the Plan to pay for the cone beam CT. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 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 for the cone beam CT provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental service provided on August 17, 2020.
You asked the Plan to pay for the dental services. You say that bitewing x-rays are covered. The Plan denied
your request. The Plan says there is no coverage for the services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The file shows that vertical bitewing x-rays (D0277), and an unspecified preventive procedure (D1999) were
provided. Although the Plan offers a dental benefit in excess of Medicare coverage, these services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental
service provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe minor restorations, periodontal maintenance, crown, first intraoral periapical x-ray, core buildup, including any pins when required, PPE, and sales tax provided from March 3, 2020, to June 30, 2020.You asked the Plan to pay forthe minor restorations, periodontal maintenance, crown, first intraoral periapical x-ray, core buildup, PPE, and sales tax. You say that your insurance coverage does not cover anything.The Plan denied your request. The Plan says these services are not covered benefits, and you did not have active coverage on March 3, 2020.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 minor restorations, periodontal maintenance, crown,first intraoral periapical x-ray, core buildup, including any pins when required, PPE, and sales tax provided from March 3, 2020, to June 30, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on January 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 the services was not filed until August 28, 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 services provided to the enrollee on January 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on July 7, 2020.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 claim was billed incorrectly.The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component testresults and was not billed as one test under code 81479.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on July 7, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that it is felt that this care is necessary.The Plan denied your request. The Plan says the criteria for this level of care are not 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 the enrollee is a female with a past medical history of dementia, diabetes, hypertension, peripheral vascular disease and chronic kidney disease who presented to the acute hospital on 12/28/2020 with right lower extremity osteomyelitis. She was treated in the hospital with vascular surgery consultation and underwent a right below the knee amputation. She is weak and deconditioned and is working with physical and occupational therapy. She is able to stand with a walker with moderate assistance and is moderate assist for transfers and is total assist for some activities of daily living. She is reported to be medically stable for discharge.Based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services, but the patient does not require an intensive inpatient rehabilitation therapy program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute 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 forthe eye exam provided on June 9, 2020.You asked the Plan to waive the copayment forthe eye exam. You say that this was for your yearly diabetic screening which is a covered preventive health service. You say that there should be no copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a planmust 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 $15 specialist copayment for Medicare covered exams to diagnose and treat diseases and conditions of the eye.You have been asked to pay a $15 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. Aneye exam for diabetic retinopathy is not considered a zero-cost preventive service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe eye exam provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran annual wellness visit (G0439) provided October 22, 2019.You asked the Plan to pay forthe annual wellness visit. You say that the visit should be covered.The Plan denied your request. The Plan says the benefit for an annual wellness exam was exhausted at the time this service was provided.The Plan must follow Medicare rules. Medicare rules say that an annual wellness exam is covered once every 12 months.We looked at the file and Medicare rules. The record shows an annual wellness exam was already billed for April 17, 2019. Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not been met.Therefore, we decided that the Plan does not have to pay foran annual wellness visit (G0439) provided October 22, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on February 29, 2020.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 claims were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. Theclaim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have topay forthe laboratory services rendered on February 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), protective restorations (D2940), and a dental extraction (D7140) to be performed by an oral surgeon.
You asked the Plan to pre-approve a comprehensive oral evaluation, protective restorations, and a dental extraction. You say that these services are needed but your general dentist denied doing it. You advised that you are diabetic and have high blood pressure which should be taken into consideration. The Plan denied your request. The Plan says the provider is not a participating general dentist.
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 a comprehensive oral evaluation, protective restorations, and a dental extraction when performed by a participating general dentist. We looked at the case file and Medicare rules. The requested services are to be performed by an oral surgeon. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, protective restorations, and a dental extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), protective restorations (D2940), and a dental extraction (D7140) to be performed by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 73565) provided on June 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 73565 is "Radiologic examination, knee; both knees, standing, anteroposterior". We asked our coding 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 services. Our reviewer says that the use of CPT code 73565 is not supported by the records provided. Our coding reviewer found that the documentation submitted did not include documentation of an x-ray taken with the patient standing. The documentation has a hand written note on it to "add standing B/L views". This does not verify that the requested service was provided. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 73565) provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the retainer crowns on tooth 28 and tooth 30 with dental code D6740 provided on June 22, 2020.
You asked the Plan to pay for the retainer crowns on tooth 28 and tooth 30. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say a plan must disclose to its enrollees the benefits offered under the plan including applicable condition and limitations. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment for dental code D6740-Retainer Crown on Tooth 28 and 30. The Plan says, per the Evidence of Coverage (EOC), these dental services are not covered to include retainer crowns on tooth 28 and tooth 30 and that bridges are only covered to replace one anterior tooth. However, the Plan contract says these services are covered once per tooth. The contract does not say anything in regards to the Plan only covering dental code D6740 on one anterior tooth. The Plan did not provide any other documentation provided to you showing that you knew that the benefit only covered one anterior tooth. We find that the Plan has not supported their reasoning for denial of payment for these services. Therefore, we decided that the Plan has to pay for the retainer crowns on tooth 28 and tooth 30 with dental code D6740 provided on June 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the leg.You asked the Plan to pre-approvean MRI of the leg. You say that an MRI is necessary.The Plan denied your request. The Plan says that Medicare coverage criteria are not met.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 an MRI of the leg. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found theposition that a plain x-ray is first necessary is not correct as even with a normal exam the MRI would still be necessary.  There is no history of trauma here.  There is a history of painful swelling of the foot which is an indication for MRI both without and with contrast to determine not only if there is a Morton's neuroma but also inflammatory conditions as well.  As an aside the location of themost intense pain, between the second and third toes is a classic location for Morton's neuroma.  The combination of history and physical findings provide a valid indication for MRI of the left foot before and after contrast injection.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 MRI of the leg have been met.Therefore, we decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the leg.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cystourethroscopy.
You asked the Plan to pre-approve Cystourethroscopy, with insertion of permanent adjustable transprostatic
implant; single implant (52441). You say that the enrollee needs the UroLift procedure. The Plan denied your
request. The Plan says the enrollee does not meet the rules in the guideline.
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 Cystourethroscopy, with insertion of
permanent adjustable transprostatic implant; single implant (52441). Our reviewer says that criteria is not met
for the requested items/services. Our physician reviewer found the 2020 AUA Guidelines regarding surgical
management of BPH specifically state that absence of obstructing median lobe is required for UroLift
procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Cystourethroscopy, with insertion of permanent adjustable transprostatic
implant; single implant (52441). have not been met. Therefore, we decided that the Plan does not have to preapprove
Cystourethroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora mandibular partial denture (D5212) purchased on February 5, 2020.You asked the Plan to pay fora mandibular partial denture. You say that you need a new set of dentures due to a tooth breakage which changed how your dentures would have to be anchored.The Plan denied your request. The Plan says rules for payment have not been met.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 a set of dentures once every 5 years. We looked at the case file and Medicare rules. You have previously received a set of dentures in July 2019. Based on this information, we decided that the Plan's rules for coverage of a mandibular partial denture have not been met.Therefore, we decided that the Plan does not have to pay fora mandibular partial denture (D5212) purchased on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating provider from June 21, 2020, to July 30, 2020.
You asked the Plan to waive the copayment for an injection. You say that you were told that these injections
would be covered. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for outpatient surgery/in-network/outpatient hospital.
You have been asked to pay a $325 copayment for an injection. The total amount you are being asked to pay is
$975 ($325 x 3 injections = $975). The injection you received falls within the outpatient surgery/innetwork/
outpatient hospital 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 an
outpatient surgery provided by a participating provider from June 21, 2020, to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forflu shot services provided on October 19, 2020 by an out of network (OON) provider.You asked the Plan to pay fortheservices provided. The Plan denied your request. The Plan says there is no authorization on file for the 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 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forflu shot services provided on October 19, 2020 by an out of network (OON) provide
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 you need physical therapy. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for total hip replacement surgery. Your condition is stable. You do not require treatment by multiple therapies, including physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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 inpatient rehabilitation facility (IRF) admission and services.