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

 
We decided that the Plan does not have to pay for the resin-based composites (D2330) for tooth 10 and tooth 
11 provided on December 14, 2020. 
 
You asked the Plan to pay for the resin-based composites. The Plan denied your request. The Plan says you met 
your annual maximum on December 7, 2020. The Plan cannot cover services beyond the $1,000 annual 
maximum, so the charges from December 14, 2020, are your responsibility. 
 
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 exceed 
the Plan's annual benefit limit. Documentation was provided to show that you had met your $1,000 maximum 
for covered services prior to the date of service in question. Therefore, we decided that the Plan does not have 
to pay for the resin-based composites (D2330) for tooth 10 and tooth 11 provided on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is medically necessary. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you have exceeded plan benefits limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from November 17, 2020 
through February 13, 2021 and March 22, 2021 through April 3, 2021. The Plan has covered 100 days of SNF 
care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the requested PET/CT scan is medically 
necessary. The Plan denied your request. The Plan says Medicare does not cover PET imaging for initial anti-
tumor strategy for prostate cancer patients. 
 
The Plan must follow Medicare rules. Medicare rules say that PET imaging for initial anti-cancer strategy is 
non-covered for enrollees with prostate cancer. Therefore, we decided that the Plan does not have to pre-
approve a PET/CT scan (78815).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient 
skilled nursing facility care. 
 
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 SNF care. Our reviewer says that 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you require 
daily skilled therapy services. However, as a practical matter, you do not require the necessary services on an 
inpatient basis, in a skilled nursing facility setting. Continued services in the acute inpatient rehabilitation 
facility until you are stable to transfer home with home health services or to a long-term care facility with part 
time services appears appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation provided in a chiropractic office 
provided from July 11, 2020, to July 23, 2020. 
 
You asked the Plan to pay for electrical stimulation. You say that this service should be covered by the Plan. 
The Plan denied your request. The Plan says electrical stimulation provided in a chiropractor's office is not 
covered. 
 
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 service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical 
stimulation provided in a chiropractic office provided from July 11, 2020, to July 23, 2020.
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 require more intense rehab than is provided at a 
skilled nursing facility (SNF). The Plan denied your request. The Plan says you do not meet the criteria for 
acute in-patient rehabilitation 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 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 that the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says stepping down to a less intensive level of service would be considered when 
patients no longer require 24-hour observation for safety, diagnostic evaluation, or treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found you doe not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of April 5, 2021 
forward, as you were not shown to be a danger to yourself or others. You were not showing any auditory or 
visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive 
behaviors or any treatment required for acute threats of safety. The health plan's denial of continued inpatient 
psychiatric services is appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an MRI with an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no gap issue, and there are in-network providers available. 
 
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 for an MRI with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided from
October 20, 2020, to November 22, 2020.
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you are on a limited
income and cannot afford this amount. The Plan denied your request. The Plan says you have been asked to pay
the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare-covered durable medical equipment and related supplies and any additional costsharing.
You have been asked to pay a total of $218.35 which is 20% of the allowed amount for the oxygen equipment.
The total allowed amount is $ 1,091.78. ($1,091.78 x 20% = $218.35). The oxygen equipment falls within the
"Durable medical equipment (DME) and related supplies" benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for the oxygen equipment provided from October 20, 2020, to November 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for vision services provided on October 28, 2020.
You asked the Plan to reimburse you for reimburse these services. You say that the Plan should reimburse you what you paid for the vision services provided. The Plan denied your request. The Plan says that the records show you are not enrolled with supplemental vision coverage beyond what is covered in the contract and this provider is not a network vision provider.
Medicare does not pay for vision services. The Plan offers vision coverage from providers within the Plans network. The provider used is not in the Plans network and the records do not show you have additional supplemental vision coverage. Therefore, we decided that the Plan does not have to reimburse you for vision services provided on October 28, 2020.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pre-approve genetic testing. We decided that the Plan does not have to pre-approve genetic testing.

You asked the Plan to pre-approve genetic testing. You say that this testing is needed to determine if your treatment is effective and to see if your children or yourself are predisposed to similar cancers. The Plan says that the denial of authorization for these tests is correct, because these tests are not covered or you do not meet the coverage criteria.

We decided that the Plan has to pre-approve genetic testing code 81455 (Next Gen 600 NGS Panel).

The Plan follows Medicare rules. Medicare rules state that next generation sequencing testing may be covered when certain criteria have been met.

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 genetic testing. Our reviewer says that this testing meets the Medicare criteria for coverage. Our physician reviewer found that you have a diagnosis of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer, has not been previously tested with the same test using next-generation sequencing for the same cancer genetic content, and decided to seek further treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing code 81455 (Next Gen 600 NGS Panel) have been met. Therefore, we decided that the Plan has to pre-approve this genetic testing.

We also decided that the Plan does not have to pre-approve genetic testing codes 88341, 88342, and 88360.

The Plan follows Medicare rules. Medicare rules state that special histochemical stains and immunochemical stains are only covered for enrollees with colorectal cancer or endometrial cancer who meet certain criteria.

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 genetic testing. Our reviewer says that this testing does not meet the Medicare criteria for coverage. Our physician reviewer found that you do not have a diagnosis of colorectal cancer or endometrial cancer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on October 13, 2020.
You asked the Plan to pay for the dental service. You say that a teaching doctor signed off after each service was performed. You say that the University accepts Medicare. You also say that you do not know how you would be aware a specific provider would not accept Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider who has opted out of Medicare.
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, dental services that are performed by a provider who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on October 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you require additional routine transportation miles to attend medical appointments. The Plan denied your request. The Plan says that your request exceeds the mileage limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on November 24, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that you received a bill, but you only have this service once a year. 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 cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Medicare-covered eye exams, including diagnosis and treatment for diseases and conditions of the eye. You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show a medical eye exam was billed due to a diagnosis of dry eye syndrome and cataracts. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) provided September 29, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that these items were medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the ordering physician and the enrollee.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the items were not medically reasonable and necessary. Our physician reviewer found there are no claims on file with the ordering physician listed in the member's claims history from 2019-present. The review has determined that the record did not support an established relationship between the member and the prescribing physician. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) provided September 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assay provided on August 6, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Medicare does not cover assays of this type ordered for screening purposes. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assay provided on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the hospital services provided on March 19, 2019, through March 21, 2019.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because the Plan did not issue recoupment until after the timely filing deadline. The Plan denied your request. The Plan says that the corrected claim was submitted after the timely filing deadline.
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 the Plan recouped payment for these services. The one calendar year begins on the date of the recoupment. This claim was filed well within one year of the recoupment. Therefore, we decided that the Plan has to pay for the hospital services provided on March 19, 2019, through March 21, 2019.
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.