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

We decided that the Plan does not have to pay for the four endosteal implants, implant removal, six surgical extractions, and two bone replacement grafts for ridge preservation provided on November 4, 2020.

You asked the Plan to pay for the endosteal implants, implant removal, surgical extractions, and bone replacement grafts. You say that you feel these services were necessary for the enrollee's full recovery. The Plan denied your request. The Plan says these services are 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 four endosteal implants, implant removal, six surgical extractions, and two bone replacement grafts for ridge preservation provided on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and the crown repair necessitated by restorative material failure (D2980) received December 23, 2020.

You asked the Plan to pay for the limited oral evaluation and crown repair. You say that you want to use your plan gift card to pay for the requested services. The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 limited oral evaluation - problem focused (D0140), and the crown repair necessitated by restorative material failure (D2980) received December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for WATS 3D biopsy testing (88104, 88305, 88312, 88361) provided on November 5, 2020.

You asked the Plan to pay for WATS 3D biopsy testing. You say that this was medically necessary. The Plan denied your request. The Plan says only the professional component can be paid for these services.

The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical component (TC) of a physician pathology service provided to an inpatient or outpatient.

We looked at the file and Medicare rules. The record shows that the testing at issue was provided to a hospital outpatient, but these services were not reported with a modifier to indicate only the professional, not technical, component is being billed. Based on this information, we decided that Medicare rules for coverage of WATS 3 biopsy testing have not been met. Therefore, we decided that the Plan does not have to pay for WATS 3D biopsy testing (88104, 88305, 88312, 88361) provided on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray and office visit provided on December 13, 2020.

You asked the Plan to pay for the additional intraoral periapical x-ray and office visit. You say that you would like the x-ray to be covered. The Plan denied your request. The Plan says your benefits for the additional intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded. The Plan also says that the office visit is not a covered 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the office visit is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on December 13, 2020 and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray and office visit provided on December 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for radiological diagnostic services with related supplies provided November 30, 2020.

You asked the Plan to waive the cost share for radiological diagnostic services with related supplies. You say that you would like this cost share waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 co-payment for Medicare-covered radiological diagnostic services.

You have been asked to pay a total cost share of $151.76 for the radiological diagnostic services with related supplies ($75 co-payment x 2 scans +$8.80 allowed amount x 20% coinsurance). The services provided fall within the Medicare-covered radiological diagnostic services benefit category and the durable medical equipment 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 cost share for radiological diagnostic services with related supplies provided November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from January 26, 2019 to February 1, 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 submitted records do not support the billed DRG and diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 308 and diagnosis code I47.1 (supraventricular tachycardia). 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 these services. Our reviewer says that the submitted records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee presented to the emergency room on January 26, 2019 with tachycardia, hypotension, and altered mental status. Hypotension was noted. The documentation supported an admission for hypotension of hemodialysis. While the enrollee did develop supraventricular tachycardia, this was indicated on January 28, 2019 after the initial admission. The records do not support the billing of DRG 308 and diagnosis code I47.1 as a primary diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from January 26, 2019 to February 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for testing evaluation services (96132) provided on September 10, 2020.

You asked the Plan to waive the copayment for testing evaluation services. You say that the charge for the service at issue is a questionable or fraudulent charge. The Plan denied your request. The Plan says the correct copayment was 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 $60 copayment for Medicare-covered diagnostic procedures/tests. The contract further states that multiple tests may result in multiple copayments. 

You have been asked to pay a $60 copayment for testing evaluation services. Testing evaluation services 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 testing evaluation services (96132) provided on September 10, 2020.

Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from the provider is 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 types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 26, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 laboratory services rendered on October 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.

You asked the Plan to provide additional routine transportation trips. You say that you have no method to get to your medical appointments. The Plan denied your request. The Plan says you have exhausted your transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride excluding varnish and palliative (emergency) treatment of dental pain provided on November 30, 2020, and December 3, 2020.

You asked the Plan to pay for the topical application of fluoride excluding varnish and palliative (emergency) treatment of dental pain. You say that you feel you should not be held responsible for these charges. The Plan denied your request. The Plan says these services are 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 topical application of fluoride excluding varnish and palliative (emergency) treatment of dental pain provided on November 30, 2020, and December 3, 2020.
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 and crown provided on December 7, 2020.

You asked the Plan to pay for the core buildup and crown. You say that you were advised that these services should be covered. The Plan denied your request. The Plan says the core buildup is not a covered service. The Plan also says that your crowns benefit has 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 core buildup is not among those covered under this benefit. The contract says that crowns are limited to two procedures per calendar year. The record shows that you received crowns on March 4, 2020, and September 21, 2020 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required and crown provided on December 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 14, 2021.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you received oral, topical, and eye medications in the SNF and had stable vital signs. You received physical, occupational, and speech therapy and need assistance with walking 80 feet with a rolling walker. You need varied levels of assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve continued skilled nursing facility (SNF) services beyond May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) and a handling or conveyance fee (99002) purchased on November 17, 2020.

You asked the Plan to pay for a portable oxygen concentrator with a handling or conveyance fee. You say that the requested item is a necessity for you. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered.

We looked at the file and Medicare rules. The requested item was purchased rather than rented. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator with a handling or conveyance fee have not been met. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) and a handling or conveyance fee (99002) purchased on November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says a SNF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problem. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services is not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation. We decided that the Plan does not have to pay for the bitewing x-rays.

You asked the Plan to pay for the bitewing x-rays and comprehensive oral evaluation. You say that you would like these services to be covered. The Plan says that your benefits for these services have been satisfied and the frequency limitations have been exceeded.

We decided that the Plan has to pay for the comprehensive oral evaluation.

The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE).

The contract says that periodontal exam or comprehensive oral evaluation are covered benefits, and is limited to one procedure every three years. The documentation says you received an exam on May 19, 2020 exhausting this benefit. The record shows that you received a periodic oral evaluation on May 19, 2020. Periodic oral evaluations are limited to two procedures per calendar year. The documentation does not show that you had received either a periodontal exam or a comprehensive oral evaluation within three years prior to this date of service. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation.

We also decided that the Plan does not have to pay for the bitewing x-rays.

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, bitewing x-rays are limited to one set per calendar year. The record shows that you received bitewing x-rays on May 19, 2020 and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays.

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: 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 can't go home because you don't have anyone to help you at home. The Plan denied your request. The Plan says your needs can be met in a less intensive setting.

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 Medicare 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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for cardiac catheterization.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network 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 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 a referral to an out-of-network provider for cardiac catheterization.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling for gingival inflammation.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services 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 pre-approve scaling for gingival inflammation.