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

We decided that the Plan does not have to pay forlab services (G0483) provided to the enrollee on December 20, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says there is an insufficient physician order or medical records submitted to determine this testing was medically necessary.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay forlab services (G0483) provided to the enrollee on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you are requesting review of denial of the 
wheelchair ramp. The Plan denied your request. The Plan says a wheelchair ramp is not covered by Medicare 
because it is not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee 
from December 3, 2019, to December 24, 2019. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 items/services at issue in this appeal. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician 
services provided to the enrollee from December 3, 2019, to December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you were approved for bed liners and 
depends. You state you really need them and the provider can provide medical records if needed. The Plan 
denied your request. The Plan says the items are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that all of your teeth on the bottom are broken 
and you have no teeth on the top and cannot chew anything. The Plan denied your request. The Plan says you 
exhausted your benefit frequency limit. 
 
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. 
 
You exhausted your benefit frequency limit., because you had received dentures on March 31, 2016. The health 
plan contract says one (1) of (D5120, D5140, D5212, D5214), once per sixty (60) months, per patient. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - mandibular (D5120).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency room visits (99283) on May 24 and May 25, 2020.You asked the Plan to waive the copayment foremergency room visits. You say that the catheter you received was placed incorrectly.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 $120 copayment for Medicare-covered emergency room visits. You have been asked to pay a $120 copayment for 2 emergency room visits. Emergency room visits fall within the "Emergency care" 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 foremergency room visits (99283) on May 24 and May 25, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the patient?s nursing, medical and rehabilitation needs do require an acute rehab 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient requires treatment 
by multiple therapies, including both physical therapy and occupational therapy, and an intensive rehabilitation 
therapy program. There is a reasonable expectation that this member will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The 
documentation indicates the patient is now requiring hemodialysis and this will need to be arranged as an 
outpatient. Although their medical conditions have stabilized, his complex medical conditions require frequent 
physician visits to remain stable. The requested admission to an IRF is medically 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an easy stand glider. 
 
You asked the Plan to pre-approve an easy stand glider. You say that the equipment is necessary and 
appropriate for home use. The Plan denied your request. The Plan says the equipment is a piece of exercise 
equipment. The Plan states the notes say the enrollee was using the device at their gym before COVID 
restrictions. The Plan states the equipment is not primarily and customarily used to serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an easy stand glider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of network medical services provided to the enrollee 
on March 17, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 items/services at issue in this appeal. The Plan 
did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for the out of network medical 
services provided to the enrollee on March 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided from May 10, 2020, through May 12, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 10, 2020 to May 12, 2020. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services from May 10, 2020, through May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe implant supported porcelain/ceramic crown provided on December 17, 2019.You asked the Plan to pay forthe implant supported crown. The Plan denied your request. The Plan says this service is not covered under your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe implant supported porcelain/ceramic crown provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe provisional crown (D2799) and post and core in addition to crown (D2952) on February 28, 2020.You asked the Plan to pay forthe provisional crown (D2799) and core in addition to crown (D2952). You say that the dentist performed necessary services.The Plan denied your request. The Plan says the servicesarenot covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dentalbenefit 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 provisional crown (D2799) and post and core in addition to crown (D2952) on February 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on 
June 12, 2020. 
 
You asked the Plan to pay for the infectious agent detection. You say that this is a covered benefit. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on 
June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral- 
complete series x-ray (D0210) and 2D oral/facial image (D0350) provided on July 1, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150), intraoral- complete series x-ray 
(D0210) and 2D oral/facial image (D0350). You say that you are appealing the denial of payment. The Plan 
denied your request. The Plan says the comprehensive oral evaluation and intraoral- complete series x-ray 
exceeds the frequency limit of the plan and the 2D oral/facial image is 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, you also have a maximum benefit of 
one comprehensive oral evaluation and one intraoral- complete series x-ray every three plan years. The Plan 
paid for a comprehensive oral evaluation and an intraoral- complete series x-ray provided on July 17, 2019, 
which exhausted your benefit. The 2D oral/facial image is not a covered benefit. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral- complete series x-ray 
(D0210) and 2D oral/facial image (D0350) provided on July 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray (71045) provided on July 16, 2020.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says secondary only diagnosis can not be used as the primary, first-listed or principal diagnosis for any procedure or service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that when there is a "code first" note and an underlying condition is present, theunderlying condition should be sequenced first, if known. We find that CPT code 71045 is not supported in the record. Specifically, the diagnosis code billed on the claim has a code first note. This means that the underlying condition should be sequenced first. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe chest x-ray (71045) provided on July 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) occupational therapy sessions, 10 speech 
therapy sessions and 10 physical therapy sessions. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our physician reviewer 
found based on review of the medical records, the enrollee does not meet the CMS coverage criteria for 
continuation of therapies with requested number of visits. The documentation does not support that there is a 
need for these therapy visits based on the enrollee's current function. The medical records provided do not meet 
the requirements listed in the rules for Medicare coverage. The enrollee's therapy needs can be met with 1-2 
more visits in each discipline to complete home exercise 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ten (10) occupational therapy sessions, 10 speech therapy sessions and 10 physical therapy 
sessions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 31, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab services provided on February 21, 2020. 
 
You asked the Plan to waive the deductible for lab services. You say that you were told you would not be 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for covered out-of-network medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $500 out-of-network deductible applies to lab tests. This cost sharing is a 
contractual obligation that had not been met at the time lab services were received on February 21, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for lab services provided on 
February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a wrist X-ray (73110) and a specialist 
office visit (99203) on January 13, 2020. 
 
You asked the Plan to waive the copayments for a wrist X-ray and a specialist office visit. You say that you 
should not be charged twice. The Plan denied your request. The Plan says the correct copayments were 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 $35 
copayment for each visit to a specialist and a $20 copayment for most X-rays and ultrasounds.  
 
You have been asked to pay a $20 copayment for a wrist X-ray and a $35 copayment for a specialist office 
visit. A wrist X-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit 
category. A specialist office visit falls within the "Physician/Practitioner services, including doctor's office 
visits" benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for a wrist X-ray (73110) and a 
specialist office visit (99203) on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular screening testing provided on February 11, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing is not a covered 
benefit for the diagnoses listed and was performed for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these 
tests for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular screening 
testing provided on February 11, 2020.