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

We decided that the Plan does not have to pay for outpatient lab work provided on December 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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. 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 outpatient lab work provided on December 30, 2019 by an out of network (OON) provider.
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 enrollee has had a 22 day hospital stay and is likely to continue to require acute care in the long term. The Plan denied your request. The Plan says the enrollee can complete care at the current facility until stable for discharge to 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 patient is currently undergoing treatment at an ACH for recurrent pleural effusions and ESRD. The enrollee suffered a cardiac arrest resulting in intubation/ventilation. The enrollee subsequently received a tracheotomy. There is no evidence that the enrollee requires services that are not currently available. 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 LTC 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on January 17, 2020.You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the urgent care charges because you do not feel your condition was urgent. You state that your doctor was not available so you saw another physician.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for urgently needed services. The medical records show that you received urgently needed services on January 17, 2020. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on November 6, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you feel that the charges should be included in a surgical procedure.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $40 copayment for specialist services. You have been asked to pay a $40 copayment for a specialist visit. A specialist 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 copayment fora specialist visit provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe wound care services provided on November 15, 2019.You asked the Plan to waive the copayment forthe wound care services. You say that you do not feel you should be liable for this copayment. The Plan denied your request. The Plan says you have been charged 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 a $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the wound care services. The wound care services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you received wound care services in a specialist's office.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 forwound care services provided on November 15, 2019.Your complaint about the wound care services in the hospital 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 31, 2019 through November 4, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that some of the hospital staff never spent more than three (3) minutes with you and you are on a very fixed income.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 October 31, 2019 and discharged on November 4, 2019. You were asked to pay a $395 copayment per day from October 31, 2019 through November 3, 2019, days 1-4 of your inpatient hospital care. You were discharged on November 4, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $395 copayment per day required for days 1-4. 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 October 31, 2019 through November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 additional intraoral x-rays (D0230) provided on January 3, 2020.You asked the Plan to pay for the 2 additional intraoral x-rays. You say that the limited oral exam was coded incorrectly and should therefore be covered by the Plan.The Plan denied your request. The Plan says 1 intraoral x-ray is covered per calendar year. The Plan also says the frequency limit for this service 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 and intraoral x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan already paid for1 intraoral x-ray that you received on January 3, 2020.Therefore, we decided that the Plan does not have to pay for the 2 additional intraoral x-rays (D0230) provided on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the extraction (D7140) provided on March 11, 2020 by an out of network provider.
You asked the Plan to reimburse the full amount for the dental services. You say that you were referred to the provider in this case as an urgent care dentist. You say that since the Plan referred you, you should be reimbursed the full amount. The Plan denied your request. The Plan says the provider in this case is not a network provider with your dental plan. The Plan also says if you choose to receive services from a non-dental plan provider, you may pay more.
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 you receive out of network are subject to a higher cost share. The record shows that the Plan directed you to an in-network dental group. The provider in this case is not associated with the in-network dental group or your Dental Plan. Therefore, we decided that the Plan does not have to reimburse the full amount for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the extraction (D7140) provided on March 11, 2020 by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestereotactic body radiation therapy (SBRT) treatments.You asked the Plan to pre-approvethe SBRT treatments. You say that this would be the best option for targeting the enrollee's spinal lesions.The Plan denied your request. The Plan says there is no evidence that this is needed over standard radiation therapy.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SBRT treatments. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that SBRT, delivering high fractional doses in 4-5 fractions,is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the patients' performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks.  SBRT has been demonstrated to achieve durable tumor control when treating lesions in vertebral bodies or the paraspinous region, where extra care must be taken to avoid excess irradiation of the spinal cord when tumor-ablative doses are administered. There is an important clinical distinction between the status of patients described above and a patient with widely metastatic disease for whom palliation is the major objective. In one setting, a patient with limited metastatic disease and good performance status is treated with the intention of eradicating all known active disease or greatly reducing the total disease burden in a manner that can extend progression free survival. For such a patient, SBRT can be a reasonable therapeutic intervention. In this case, the ASTRO Policy criteria do not appear to be met as the enrollee has widespread metastatic disease with multiple prior treatments for bone metastases. Studies showed no benefit of SBRT over conventional radiotherapy for the treatment of spine metastases with respect to pain control at 3 months or quality of life. Therefore, routine use of SBRT for spine metastases is not indicated. As such, SBRT would not be considered to be furnished in accordance with accepted standards of care for this enrollee.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 SBRT treatments have not been met.Therefore, we decided that the Plan does not have to pre-approvestereotactic body radiation therapy (SBRT) treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea retainer crown (D6752) and a pontic (D6242).You asked the Plan to pre-approvethe dental services. You say that you donot have any teeth on the lower left side of your mouth. You also say that you need these services in order to have a better quality of life.The Plan denied your request. The Plan says the requested retainer crown and pontic are not listed as 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea retainer crown (D6752) and a pontic (D6242).
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) scan of the head without dye provided
on November 9, 2019.
You asked the Plan to pay for the physician service. You say that the enrollee was receiving hospice care until
November 8, 2019. You say that she was hospitalized and treated for a condition that was unrelated to her
hospice admission and therefore should have been covered. The Plan denied your request. The Plan says that
the services that the enrollee received are covered under Original Medicare and not her Medicare Advantage
Plan.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide documentation that would substantiate that the enrollee
was enrolled in Hospice and when. Without the documentation to show this we cannot confirm that the services
should have been billed to Original Medicare. Therefore, we decided that the Plan has to pay for the computed
tomography (CT) scan of the head without dye provided on November 9, 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90832) provided April 15, 2019 to November 18, 2019.You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the opt-out provider. This provider has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90832) provided April 15, 2019 to November 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a
participating provider on February 14, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the member was
recommended for a colorectal cancer screening. The Plan denied your request. The Plan says the correct
copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $300 copayment for outpatient surgery.
The enrollee has been asked to pay a $300 copayment for a diagnostic colonoscopy. Evidence was provided
that showed a polyp was discovered and removed. The rules say that, if during the course of the screening
colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate
diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic
colonoscopy falls within the outpatient surgery benefit category. This means that the enrollee has been asked to
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive
the copayment for a diagnostic colonoscopy provided by a participating provider on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on September 6, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you did not purchase a supplemental dental benefit with the Dental PPO.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal exam (D0180) and the complete series of x-rays (D0210) provided on February 13, 2020.
You asked the Plan to pay for the dental services. You say that you thought the services would be covered. The Plan denied your request. The Plan says the comprehensive periodontal exam and the complete series of x-rays are not listed as 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 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 comprehensive periodontal exam (D0180) and the complete series of x-rays (D0210) provided on February 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 19, 2020.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the claim processed 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 $240 copayment for per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $240 copayment for the ambulance transport. The ambulance transport falls within the ground ambulance trips 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 the ambulance transport provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 20,
2020.
You asked the Plan to waive the copayment for laboratory services. You say that the blood test was part of your
physical that you get every year at no charge. 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 $30 per
day, per in-network provider, for Medicare-covered lab services.
You have been asked to pay a $30 copayment for the laboratory services. Laboratory services fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests
are considered a separate service. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services
provided on January 20, 2020.