Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 10, 2019.You asked the Plan to pay forthe services. You say that this was medically necessary testing.The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.The Plan must follow Medicare rules. Medicare rules say that all information must corroborate the documentation in the record and support that coverage criteria are met. In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for an empyema in the setting of recently diagnosed lung cancer. The enrollee is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 18, 2019 through August 23, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 18, 2019 and discharged on August 23, 2019. You were asked to pay a $370 copayment per day from August 18, 2019 through August 22, 2019, days 1-5 of your inpatient stay. You were discharged on August 23, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5 each time you are admitted to the hospital. 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 inpatient hospital care from August 18, 2019 through August 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from October 23, 2019 to November 27, 2019.You asked the Plan to pay for the psychotherapy services. You say that this provider was in-network when you signed up for this Plan. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 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 for psychotherapy servicesprovided from October 23, 2019 to November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the comprehensive oral evaluation (D0150), the bitewing x-rays (D0274), the prophylaxis (D1110), the resin based composite, 2 surfaces, for an anterior tooth (D2331), and the resin based composite, 2 surfaces, for a posterior tooth (D2392) provided from October 16, 2019 to October 24, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the annual maximum of $2,000 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 annual maximum benefit has been exceeded.
Date of Service
Billed Amount
Allowed Amount
Plan Paid
1/15/2019
$1,076
$973
$973
2/19/2019
$94
$83
$83
3/28/2019
$120
$116
$116
6/8/2019
$120
$95
$95
7/23/2019
$235
$204
$204
8/7/2019
$1,076
$973
$529
TOTAL:
$2,000
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the comprehensive oral evaluation (D0150), the bitewing x-rays (D0274), the prophylaxis (D1110), the resin based composite, 2 surfaces, for an anterior tooth (D2331), and the resin based composite, 2 surfaces, for a posterior tooth (D2392) provided from October 16, 2019 to October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe aflibercept injection provided on July 23, 2019.You asked the Plan to waive the coinsurance forthe injection. The Plandenied your request. The Plan says that cost-sharing is a contractual obligation of 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 20% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B Prescription Drugs 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 aflibercept injection provided on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on October 17, 2019.You asked the Plan to pay forthe dental services. You say that you had no way of knowing what would be covered. You say that you did not know that the provider was doing additional x-rays that were not covered.The Plan denied your request. The Plan says the periapical x-rays are not covered 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 23, 2019 to September 30, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The claim was billed with diagnosis code D63.1, which is a manifestation code. This code cannot be billed as a primary diagnosis. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 23, 2019 to September 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for Budesonide Suspension.You asked the Plan to pre-approve the tier exception. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Part B covered products are not eligible for reduction to a lower co-payment.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Specifically, the 2020 EOC states that the member is responsible for a $0 copayment for Medicare Part B prescription drugs. Medicare Part B drugs are not eligible for tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Budesonide Suspension.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on July 16, 2019.You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 Plandid not pre-approve the services at issue. We found no exception that wouldrequire the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for genetic testing provided on July 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary team approach for rehab care.
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 physician reviewer found that the enrollee's current level of function is ambulation of 70 feet, and standby assist for sit to stand. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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 for the enrollee.
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 referral to the facility is due to lower extremity swelling, fatigue with shortness of breath, severe kyphoscoliosis and lumbar region tenderness that is worsening. You say that the enrollee is willing and able to participate in 3 hours of therapy daily to improve her endurance and improve her ability to perform daily tasks at home safely and consistently. The Plan denied your request. The Plan says Medicare guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another 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 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical therapy and occupational therapy but does not require this on an intensive rehabilitation facility therapy program level 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on October 25, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you should have been informed the lab work would cost more at a hospital.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all costsharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 copayment for lab services at an in-network outpatient hospital. You have been asked to pay $16, which is less than the standard $70 copayment for laboratory services. Laboratory services fall 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 forlaboratory services provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 98943) provided to the enrollee from September 27, 2019, to October 16, 2019.
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not manipulation of the spine.
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 records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 98943) provided to the enrollee from September 27, 2019, to October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for 60mg Prolia.
You asked the Plan to pre-approve the tier exception. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this drug is covered by Part B and is not eligible for a tier exception.
The Plan must follow Medicare rules. a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Specifically, Prolia is a Medicare Part B prescription drug and not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for 60mg Prolia.
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 the services are needed.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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but your functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build up (D2950) for teeth # 18 and 22, the pontics(D6245) for teeth # 19, 20, and 21, and the retainer crowns (D6740) for teeth # 18 and 22 provided on September 12, 2019.You asked the Plan to pay forthe dental services. You say that you cannot afford to pay for the services that you received.The Plan denied your request. The Plan says core build up is not a covered service. The Plan also says that bridges are not a covered service either.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe core build up (D2950) for teeth # 18 and 22, the pontics (D6245) for teeth # 19, 20, and 21, and the retainer crowns (D6740) for teeth # 18 and 22 provided on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of LTACH services. The Plan says that the services required can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee's ongoing care needs include aspiration precautions, surveillance
laboratory studies, intravenous antibiotics, oral vancomycin, sacral wounds, and therapy services. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.