Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says LTACH admission is not 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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having initially been placed on observation status with shortness of breath. A week later, the enrollee suffered a cardiac arrest and was intubated/ventilated. LTACH was subsequently requested, without documentation of ventilator weaning, failed weaning or tracheotomy placement. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image provided on August 22, 2019.You asked the Plan to pay forthe 2D oral/facial photographic image. You say that the provider you saw was given to you by the Plan. You also say that this provider was said to be in-network with your plan.The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 2D oral/facial photographic image provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite, 2 surfaces (D2331), and the resin based composite, 1 surface, (D2330 x 2) provided on July 23, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says dental services are not covered.
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 the resin based composite, 2 surfaces (D2331), and the resin based composite, 1 surface, (D2330 x 2) provided on July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that theenrollee needs to regain a prior level of function and continue a multidisciplinary approach to care.The Plan denied your request. The Plan says there is no advantage in moving the enrollee from the current acute care hospital.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with pneumonia. The enrollee has a tracheotomy and feeding tube at baseline. He suffered a cardiac arrest and was placed on a ventilator. The enrollee has since been weaned from the ventilator, but exhibits neurologic deficits/dysfunction. He appears to have a poor long-term prognosis.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 haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on July 22, 2019.You asked the Plan to pay forthe 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 has network providers available who can provide 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 forthe medical services provided by an out-of-network provider on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays provided on September 11, 2019.You asked the Plan to pay forthe intraoral x-rays. You say that the provider's office failed to verify if a complete series of radiographic images were within the qualifying frequency allowed within the guidelines of your policy.The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.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 benefitin excess of Medicare coverage, intraoral -complete series of radiographic images are limited to one procedure every three years. The record shows that you received a complete series of intraoral x-rays on September 8, 2017 and your intraoral -complete series of radiographic images benefit is now exhausted.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays provided on September 11, 2019.Your complaint about the negligence of the provider and their office staff 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for physician's services with a ship doctorprovided on February 9, 2019.You asked the Plan to reimburse you for the physician's services with a ship doctor/The Plan denied your request. The Plan says out of country services are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say thatitems and services furnished outside the United States are excluded from coverage. Services not furnished in a United States port, orwithin 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of United States registry.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physician's services with a ship doctorhave not been met. Therefore, we decided that the Plan does not have to reimburse you for physician's services with a ship doctorprovided on February 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on August 15, 2019.You asked the Plan to pay forthe physician services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 forthe physician services provided on August 15,2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on August 29, 2019 by "the dental group". You asked the Plan to pay forthe dental service. You say that you need a new bridge. You say that the teeth the bridge were supposed to hold onto were decaying. You say that the dentist had to extract the teeth.The Plan denied your request. The Plan says 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 evaluations are a covered service, the frequency limit has been exceeded for this service. The record shows you last received a limited oral evaluation on May 24, 2019 and June 14, 2019.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) provided on August 29, 2019 by "the dental group".
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic screening testing provided by "the provider" on June 1, 2019.You asked the Plan to pay forgenetic tests. You say that this claim should not have been denied because the laboratory results paper states that the insurance provider paid for the testing with no cost to you.The Plan denied your request. The Plan says the denial of payment for these services is correct because this provider is out-of-network with the Plan, the ordering physician is out-of-network with the Plan, andinsufficient medical records were submitted to support coverage for these tests.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 contract with the Plan says that the Plan has to pay forcare from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The testsat issue in this appeal, genetic tests, wererequested solely for screening purposes. Medicare does not cover thesetestssolely for screening purposes.Furthermore, this provider is out-of-network with the Plan, the ordering physician is also out-of-network with the Plan, and the Plan did not authorize these tests. Therefore, we decided that the Plan does not have to pay forgenetic screening testing provided by "the provider" on June 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmological services including a medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) provided on September 12, 2010.You asked the Plan to waive the copayment fora diagnostic eye exam. You say that this was billed incorrectly. You were at your routine eye exam. You were never advised as to any other screenings and should not be charged this copayment.The Plandenied your request. The Plan says vision care has a $35 copayment to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk.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 vision care. You have been asked to pay a $35 copayment for a diagnostic eye exam. This servicefalls within the vision care benefit category. The record shows that your servicewas more than routine as it was billed correctly for a diagnostic eye exam and a treatment plan. 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 forophthalmological services including a medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) provided on September 12, 2010.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit provided on October 17, 2019.You asked the Plan to waive the copayment fora specialist office visit. You say that you went for an injection. You say that you went in the office and the nurse told you that you could not get the shot because of the medication you were on.The Plan denied your request. The Plan says since a specialist office visit was provided, the correct copayment has been applied.The rules say a plan must disclose to its enrolleesin 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 physician/practitioner services/specialist visit. You have been askedto pay a $45 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 office visit provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose monitor provided on August 18, 2019.
You asked the Plan to pay for a one-month supply allowance for a therapeutic continuous glucose monitor (K0553). You say that you are billing according to Medicare guidelines. The Plan denied your request. The Plan says that that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery.
The Plan must follow Medicare rules. The rules state that a supplier does not have to deliver supplies used with a therapeutic CGM every month in order to bill code K0553 every month. In order to bill code K0553, the supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month following the DOS on the claim. No more than 1 unit of service (UOS) for code K0553 per month is billable at a time. Regardless of utilization, a supplier must not dispense more than a three (3) - month quantity of BGM testing supplies at a time. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a one-month supply allowance for therapeutic continuous glucose monitor have been met. Specifically, the supplies in this case were delivered in a 90-day supply for K0553, which the Proof of Delivery supports. The supplier is only billing one unit of K0553 at a time for supplies that are sufficient for one full month following the DOS on the claim. The supplier in this case is billing in accordance to Medicare rules for continuous glucose monitoring supplies.
Therefore, we decided that the Plan has to pay for a one-month supply allowance for a therapeutic continuous glucose monitor provided on August 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse $150 of the dental allowance for the periodontal maintenance (D4910), and the complete series of intraoral x-rays (D0210) provided on July 23, 2019.
You asked the Plan to reimburse $150 of the dental allowance for the dental services. You say that you submitted a claim for an exam, x-ray, and a cleaning. You also say that the services you received were preventive and covered based on the Evidence of Coverage. The Plan denied your request. The Plan says periodontal maintenance is considered a deep cleaning and therefore is not a preventive dental service. The Plan says intraoral x-rays are not listed as a covered service. The Plan also says only preventive dental services are covered.
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 periodontal maintenance, and complete series of intraoral x-rays are not among those covered under this benefit as they are not preventive in nature. Therefore, we decided that the Plan does not have to reimburse $150 of the dental allowance for the periodontal maintenance (D4910), and the complete series of intraoral x-rays (D0210) provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered to the enrollee by "the provider" on September 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.The provider submitted a claim for procedure code99153. This code has a PC/TC indicator of 3 and has no separate PC payment. Payment is included in the facility payment.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services rendered to the enrollee by "the provider"on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received from March 14, 2019, to August 6, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this provider is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The requested provider is a licensed professional counselor. This typeof provider is not eligible to enroll in theMedicare program. Payment cannot be made to providers who are not enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay forthe services you received from March 14, 2019, to August 6, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fluoroscopic guidance for needle placement services coded 77002 provided on September 23, 2019.You asked the Plan to pay forthe fluoroscopic guidance for needle placement services. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services billed are missing required information.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure).We find that CPT code 77002 is not supported in the medical record. Specifically, this code was billed without an appropriate primary code and not performed by the same practitioner on the same date of service. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance for needle placement services have not been met.Therefore, we decided that the Plan does not have to pay forthe fluoroscopic guidance for needle placement services coded 77002 provided on September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more forthe resin-based composite provided on June 26, 2019.You asked the Plan to pay more forthe resin-based composite. You say that this was an emergency because you broke the back of your tooth.The Plan denied your request. The Plan says this service exceeded your benefit limits.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 Plan offers a $225 allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual allowance benefit on June 26, 2019 and your annual allowance benefit has been exhausted.Therefore, we decided that the Plan does not have to pay more forthe resin-based composite provided on June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 31, 2019 by out of network provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe laboratory services provided on May 31, 2019 by out of network provider.