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

We decided that the Plan does not have to pay for an x-ray (73562) on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you are appealing an x-ray done on September 11, 2019  You thought this order from the provider's office had been previously approved. You were wrong and will not let it happen again. The next time you have any medical services for you will make sure they have prior authorization from you. The Plan denied your request. The Plan says these radiology services can be provided in-network by a contracted provider.
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 an x-ray (73562) on September 11, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to hold you harmless for the hospital services received from September 21, 2019 to September 23, 2019 minus any cost share requirement.You asked the Plan to pay for the hospital services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services received are not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were provided the hospital services by physician. Physician is a contract provider. The file does not show that plan provided notice that the hospital services would not be covered. Under Medicare rules, this means the hospital services is considered approved by plan.Therefore, we decided that the Plan has to hold you harmless for the hospital services received from September 21, 2019 to September 23, 2019 minus any cost share requirement.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: Favorable

We decided that the Plan has to pay for the wound cleanser provided by provider on August 8, 2019.You asked the Plan to pay for the wound cleanser (A6260). You say that you needed the cleanser to heal your wound from the inside out.The Plan denied your request. The Plan says that wound cleansers are not covered by Medicare or the Plan. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were referred for the wound cleanser (A6260) by provider. provider is a contract provider. The file does not show that the plan provided notice that the wound cleanser (A6260) would not be covered. Under Medicare rules, this means the wound cleanser (A6260) is considered approved by the plan. Therefore, we decided that the Plan has to pay for the wound cleanser provided by provider on August 8, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an eye exam (92012) with the out of network (OON) provider.
You asked the Plan to pre-approve this service. You say that you have been under the care of this physician for more than ten years and you were told that she would be continuing to care for you since she is an authorized provider. The Plan denied your request. The Plan says that you requested services with an out of network provider. The Plan requires you to receive care from providers who are part of your primary care physician's specialty network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider in your primary care physician's network. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an eye exam (92012) with the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for multiple tooth extractions, 9 teeth total, numbers 15, 19, 29,
5, 6, 8, 9, 12, & 13 provided on August 1, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your 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.
Your dentist states in your dental record that you presented to the office for
removal of your remaining teeth and fitting of dentures, you had several teeth pulled, an immediate denture was
fitted and placed, and you were given the choice of denture color, billed as D5899 Unspecified Removable
Prosthodontic Procedure. Traditional Medicare does not provide coverage benefits for routine dental
procedures. The Plan can confirm you have a supplemental dental plan which covers dental extractions to the
limit of 2 teeth per calendar year and immediate dentures. The Plan has approved payment for two dental
extractions (teeth numbers 2 & 4) and your immediate denture. We are still unable to approve payment for the
additional tooth extractions, totaling 9 teeth. Extraction of more than 2 teeth per calendar year is not a covered
benefit under your Medicare and plan. Therefore, we decided that the Plan does not have to pay for multiple
tooth extractions, 9 teeth total, numbers 15, 19, 29, 5, 6, 8, 9, 12, & 13 provided on August 1, 2019 by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the adjunctive procedures provided from May 21, 2019
to July 9, 2019.
You asked the Plan to hold you harmless for the adjunctive procedures. You say that this provider gave you the
receipts without a diagnosis or Current Procedural Terminology (CPT) codes. You also say that these services
were for extractions and you thought they would be covered by your plan. The Plan denied your request. The
Plan says that you do not have any supplemental benefit that will apply to cover these services.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
You were referred for the adjunctive procedures by this provider. This provider is a contract provider. The file
does not show that plan provided notice that the adjunctive procedures would not be
covered. The record shows that the correct procedure codes were requested but the facility has given excuses
for not providing them or stamping the receipts. Under Medicare rules, this means the adjunctive procedures
are considered approvedTherefore, we decided that the Plan has to hold you
harmless for the adjunctive procedures provided from May 21, 2019 to July 9, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the methylprednisolone acetate provided on November 3, 2019.
You asked the Plan to pay for the methylprednisolone acetate. The Plan denied your request. The Plan says that that they will only pay up to the fee schedule amount.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. You were referred for the methylprednisolone acetate  The file does not show that  provided notice that the methylprednisolone acetate would not be covered at 100%. Under Medicare rules, this means the methylprednisolone acetate is considered approved Therefore, we decided that the Plan has to pay for the methylprednisolone acetate provided on November 3, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for CxBladder testing provided on August 1, 2019.
You asked the Plan to pay for CxBladder test. You say that you are requesting coverage for this test. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is considered experimental/investigational.
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. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 specify whether the ordering physician is in-network or out-of-network. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Although the record does include a denial notice, this notice was provided after the service had already been rendered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this claim. Therefore, the Plan has not shown that their decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for CxBladder testing provided on August 1, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient pulmonary rehabilitation
You asked the Plan to pre-approve the outpatient pulmonary rehabilitation. You say that the provider is approximately 3 miles from the enrollee's home. You say that the travel to the other facility is extremely taxing and expensive, and often requires the enrollee to consume several tanks of oxygen per round trip. You say that 4 hours of travel time per week causes an additional heavy burden on the enrollee and her family. The Plan denied your request. The Plan says the requested services are available within the network of providers.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from the enrollee's home who can provide the outpatient pulmonary rehabilitation Under Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we decided that the Plan does not have to pre-approve outpatient pulmonary rehabilitation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says the lower partial denture would not be considered essential for either function or esthetics base on policy guidelines. The Plan also says that the lower partial denture would not be within the scope of policy coverage.
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 dental item when the services are medically necessary and reasonable. 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 dental item. Our reviewer says that the partial denture does not meet the criteria for coverage. Our physician reviewer found since an upper partial denture has been approved, there would be more than eight points of posterior contact present. The reviewer found that with only tooth # 18 missing on the lower arch, aside from the third molars, there would be no medical necessity for a lower partial denture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rheumatology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON rheumatology services. You say that you have been seeing this provider since October 2018. She is close by and is willing to be paid the same rate as your PCP which saves you and the plan money. The Plan denied your request. The Plan says there are several nearby in-network rheumatologists, including a provider which is less than 30 minutes from your home. Since there are accessible providers for this, ongoing care with the OON rheumatologist is not required. However, one transitional visit has been approved to allow time to establish care with a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve continued rheumatology services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crown on tooth #14.
You asked the Plan to pre-approve the crown. You say that the clinical exam revealed recurrent decay around the existing amalgam filling on tooth #14 and the enrollee requested treatment to stop the decay process. You also say that a full coverage crown is needed due to the excessive size of the amalgam filling. The Plan denied your request. The Plan says that the x-rays do not show that the tooth has a lot of tooth missing from a cavity or has a lot of damage from being broken. The Plan also says that the service is not medically necessary.
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 crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the service is medically necessary. Our physician reviewer found due to the large defective restoration and documented cracks in the enamel structure of tooth #14, a crown restoration is reasonable and necessary to restore the tooth to proper function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve the crown on tooth #14.
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: 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 requires acute dialysis and ultra-filtration with intermittent CRRT and extensive rehabilitation, all of which cannot be provided in a skilled nursing facility. You say that the enrollee is appropriate to discharge. The Plan denied your request. The Plan says the enrollee does not require vent weaning, complex wound management, or complex IV medicines. The plan says that the need for continued care can be safely managed in an alternative level.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) following cardiothoracic surgery. Our physician reviewer found that the enrollee is receiving hemodialysis, taking orals and participating in rehabilitative services. Our physician reviewer found that the enrollee is not intubated/ventilated. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required and 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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212), and an application of a multi-layer compression system (29581) provided on February 18, 2019 by out of network provider.You asked the Plan to pay for an office visit, and an application of multi-layer compression system. You say that you are appealing the denial stating that the Plan was unaware that the member had retro-actively instated into the plan.The Plan denied your request. The Plan says the member must use network providers to get medical care and services. The Plan says the only exceptions are emergencies, urgently needed care when the network is not available, out-of-area dialysis services, and cases in which the plan authorizes the use of out-of-network providers. The Plan says that the claim did not meet the urgent or emergent criteria based on the CPT codes and diagnosis codes submitted. The member is enrolled in an HMO plan with no out of network benefits. There is no indication any attempt was made to obtain prior authorization for these out of network services as well as an in-network referring provider for the services in the appeal.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 record shows that after searching for the provider, he was not found on the in-network list. 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 an office visit (99212), and an application of a multi-layer compression system (29581) provided on February 18, 2019 by out of network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for a general health panel provided by provider on November 11, 2019.You asked the Plan to hold you harmless for general health panel. You say that this is a useful test that your doctor performs each year that you go for a yearly checkup.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test code is not covered by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were referred for general health panel by provider. provider is a contract provider. The file does not show that plan provided notice that general health panel would not be covered. Under Medicare rules, this means general health panel is considered approved by the plan.Therefore, we decided that the Plan has to hold you harmless for a general health panel provided on November 11, 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.