Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider on October 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at 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 the services provided to the enrollee by an out-of-network
provider on October 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided December 3, 2020.

You asked the Plan to provide additional payment for the upper and lower dentures. You say that the Plan referred you to this dentist and should pay the remaining balance. The Plan denied your request. The Plan says you have used your full $1,0000 dental allowance and therefore no further payment from the Plan is due.

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. The Plan covers the upper and lower dentures when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. The Plan provided documentation that the full dental allowance has been applied to your claims in 2020. Based on this information, we decided that the Plan does not have to provide additional payment for the immediate denture - maxillary (D5130) and immediate denture - mandibular (D5140) provided December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee has no acute symptoms that require 24-hour care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

Continued inpatient services from May 5, 2021, forward were requested. 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 continued services. Our physician reviewer found that active treatment was not taking place. The requested services were not reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Services could be provided in a lesser restrictive setting as you were not showing any active suicidal or homicidal ideation, auditory or visual hallucinations and were not showing any aggressive behaviors.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Positron emission tomography (PET) (78815) provided on October 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for PET scan. You say that please review the attached medical records to support the services and reprocess the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 Positron emission tomography (PET) (78815) provided on October 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture retainer (D6750) and pontic (D6240).
You asked the Plan to pre-approve dental services. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for these services are correct, because dental services D6750 and D6240 are not covered by the Plan's dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a fixed partial denture retainer (D6750) and pontic (D6240).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that it will endanger the enrollee's mental health and it could possibly lead to her going somewhere unsafe if she does not have a safe place to go. The Plan denied your request. The Plan says that that the enrollee is receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.

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 services. Our reviewer says that SNF services are medically reasonable and necessary for the enrollee in this case. The enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee's condition meets Medicare criteria for SNF services.

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 services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) services for the enrollee.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81403, 81404, 81404, 81405, 81405, 81406, and 81406) provided October 10, 2020.

You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.

The Plan must follow Medicare rules. Medicare rules say that providers must use CPT 81479 to report a Guardant360 molecular pathology genomic profiling for lung cancer. 

We looked at the file and Medicare rules. The provider submitted the claim using unbundled CPT codes and not CPT 81479 as required. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81401, 81402, 81403, 81403, 81404, 81404, 81405, 81405, 81406, and 81406) provided October 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after May
5, 2021.
You asked the Plan to pre-approve SNF care. You say that you suffered a stroke and need care in order to get
better. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after
May 5, 2021 is correct.
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 daily
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You can be discharged to a lower level of care for further services. You do not require daily skilled
nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.
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 continued Skilled Nursing Facility (SNF) care after May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection (20611) triamcinolone acetonide injection (J3301) provided December 17, 2020.
You asked the Plan to waive the copayment for the injection services. You say that why should you pay your copay of $40 for each visit and still owe for a shot in your frozen shoulder. You took physical therapy for 8 weeks and paid $40 copay each visit. Why not pay for this? The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 $40 copay for surgery services in a specialist office and 20% coinsurance for Medicare Part B covered drugs. You have been asked to pay $42.13 ($40 + $2.13) for the injection services. The injection services fall within the Physician/Practitioner services, including doctor's office visits and Medicare Part B prescription drugs benefit categories. 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 arthrocentesis, aspiration and/or injection (20611) triamcinolone acetonide injection (J3301) provided December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81120, 81121, 81173, 81201, 81210, 81270,
81272, 81275, 81293, 81299, 81310, 81311, 81314, 81318, 81321, 81404, 81404, 81405, 81405, 81406)
provided December 16, 2020.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan
denied your request. The Plan says this service was incorrectly billed.
The Plan must follow Medicare rules. Medicare rules say that providers must use CPT 81479 (unlisted
molecular pathology procedure) for reporting the Guardant360 panel assay.
We looked at the file and Medicare rules. The procedure must be reported using CPT 81479 and not be
unbundled. Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (81120, 81121, 81173,
81201, 81210, 81270, 81272, 81275, 81293, 81299, 81310, 81311, 81314, 81318, 81321, 81404, 81404, 81405,
81405, 81406) provided December 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services provided by a participating provider on November 29, 2020.
You asked the Plan to waive the copayment for observation services. You say that you do not believe you owe this. 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). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient hospital observation. You have been asked to pay a $275 copayment for observation services. The correct copayment has been applied to the services that were provided. Observation services fall within the outpatient hospital observation 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 observation services provided by a participating provider on November 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December
28, 2020.

You asked the Plan to pay for the dental service. You say that this is a ridiculous evaluation. You say that this
was simply for diagnosing a sore gum that determined deep cleaning is required. You say that this is totally
inconsistent with the dental benefit. You also say that you have not even approached the $1,000 benefit limit.
The Plan denied your request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also
says that the frequency limit 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 limited oral evaluation is listed as a
covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral
evaluation that you received on September 15, 2020. Therefore, we decided that the Plan does not have to pay
for the limited oral evaluation (D0140) provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 20, 2021 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that there are in-network providers available for 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 had network providers
available who could have provided 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 physician services provided on January 20, 2021
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 20, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have 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 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 10, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you should not have to pay for the mammogram. You say that the services should be covered as preventive. 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 $155 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay $97.89, which is less than the standard $155 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The ultrasound is considered a diagnostic 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 the ultrasound provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on October 11, 2019.
You asked the Plan to pay for the home visit. You say that the provider was called in to treat the member for the medically necessary services which should be covered under the facility's authorization. You say that the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and did not obtain authorization for the 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 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 home visit provided by an out-of-network provider on October 11, 2019.