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

We decided that the Plan has to pay for laboratory testing provided on July 7, 2015.
You asked the Plan to pay for lab tests. You say that you submitted this claim within the timely filing limit. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
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 rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. 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 submit evidence to show that this claim was submitted outside of the timely filing limit. Without this information, the Plan has not shown that its decision to deny payment for these services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on July 7, 2015.
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 pay for extraction teeth 7,8,9,10,20,21,23,26,28,29 (D7140) surgical extraction teeth 3, 11,14, 22, 27 (D7210) immediate lower denture (D5130) immediate upper denture (D5140) provided February 5, 2019.
You asked the Plan to pay for the dental services. You say that payment is being declined and you believe that it should be covered. The Plan denied your request. The Plan says the frequency limitations has been exceeded. The coinsurance applied correctly.
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 health plan contract covers 1 extraction is per year. The plan approved payment for D7210 tooth #3. Therefore, the remaining extractions performed are not covered. 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 extractions teeth 7,8,9,10,20,21,23,26,28,29 (D7140) surgical extractions teeth 11,14, 22, 27 (D7210) provided February 5, 2019.
The health plan contract says that there is a 50% coinsurance. The plan had approved payment for D7210 (tooth 3), D5130 and D5140 and the 50% coinsurance was applied. The services fall within the Dental services benefit category. This means 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 wave the coinsurance for the surgical extraction teeth 3 (D7210) immediate lower denture (D5130) and immediate upper denture (D5140) provided February 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided from March 8, 2016 to June 1, 2016.
You asked the Plan to pay for drug tests. You say that you are requesting that these services be paid at the in-network rate. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that claims for drug tests were not filed until December 30, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for drug testing provided from March 8, 2016 to June 1, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCooled radiofrequency ablation (RFA) at L3, L4, and L5.You asked the Plan to pre-approveCooled radiofrequency ablation (RFA) at L3, L4, and L5. You say that the requested Cooled RFA is medically necessary.The Plan denied your request. The Plan says the requested Cooled RFA does not meet criteria.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 Cooled radiofrequency ablation (RFA) at L3, L4, and L5. Our reviewer says that the requested Cooled RFA does not meet criteria. Our physician reviewer found the enrollee is diagnosed with spondylosis without myelopathy or radiculopathy, lumbar region and lumbosacral region.  Cooled RFA remains experimental at this time. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of Cooled radiofrequency ablation (RFA) at L3, L4, and L5 have not been met.Therefore, we decided that the Plan does not have to pre-approveCooled radiofrequency ablation (RFA) at L3, L4, and L5.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 based on the documentation provided, the enrollee is currently undergoing treatment
at an acute care hospital (ACH) for COVID-19. The enrollee required intubation/ventilation and subsequently
received a tracheotomy. The enrollee remains on a ventilator and is not tolerating pressure support trials. The
enrollee continues to receive care for multiple problems and complications. There is no evidence that the
enrollee requires services that are not available at the current facility. As LTACHs and ACHs are licensed to
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Medicare
criteria for transfer are not met. 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the regadenoson injection provided on February 12, 2020.
You asked the Plan to waive the coinsurance for the injection. The Plan denied your request. The Plan says that Medicare Part B drugs are covered with 20% coinsurance.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs 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 coinsurance for the regadenoson injection provided on February 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere are no complex medical needs that would require frequent monitoring by a hospital level doctor.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can beprovided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician visit. You say that the provider cannot contact the Plan before service to verify if authorization was obtained. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 the medical services provided on August 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) prophylaxis (D1111) and periapical x-ray (D0220) provided on December 23, 2019.
You asked the Plan to pay for the dental services. You say that you were not happy with your first dentist and went to a different in-network dentist. You were not informed the other visit was considered a second cleaning and would not have taken her to the December visit. The Plan denied your request. The Plan says these services exceeds the frequency limitations.
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. Records show that these services were approved and paid for by the plan for dates of service 5/31/2019 and 06/07/2019. Therefore the benefits have been exhausted. 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 periodic oral exam (D0120) prophylaxis (D1111) and periapical x-ray (D0220) provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on January 7, 2020.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says that the documentation submitted did not include a valid physician order/lab requisition or medical records.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be safely received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the patient does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health services appears to be more appropriate in this case.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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services. on November 18, 2019.
You asked the Plan to pay for the physician's services. You say that you rely on the facility to obtain the authorization and the medical records support the medical necessity for this service. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 physician's services on November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 23, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 servicesat 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 physician's services provided on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral noninvasive studies of the lower extremities to
be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network bilateral noninvasive studies of the lower extremities.
You say that the enrollee resides at a rehab and nursing home and cannot independently ambulate. You say
that you have an outpatient office at the facility where you're requesting the services be authorized to be
rendered. You say that the requested services are medically reasonable and necessary. The Plan denied your
request. The Plan says there are in-network providers who can provide the requested 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 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
bilateral noninvasive studies of the lower extremities to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study provided on February 18,
2020.
You asked the Plan to waive the copayment for the sleep study. You say that the test was improperly run. You
say that you shouldn't have to pay for improper testing. 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 $0
copayment for diagnostic procedures and tests at a physician's office and a $99 copayment for procedures at
any other location.
You have been asked to pay a $99 copayment for the sleep study. The sleep study falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" 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 sleep study provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound and an office visit provided
by a participating provider on January 13, 2020.
You asked the Plan to waive the copayment for an ultrasound and an office visit. You say that these
copayments are too high. 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services and a $15
copayment for physician/practitioner services/specialist services.
The enrollee has been asked to pay a $110 copayment for an ultrasound and a $15 copayment an office visit.
An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services benefit category and
an office visit falls within the physician/practitioner services/specialist services benefit category. The total
amount you are being asked to pay is $125 ($110 + $15 = $125). 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 an ultrasound and an office visit provided by a participating provider on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial mandibular overdenture (D5866) provided on
January 30, 2020.
You asked the Plan to pay for the partial mandibular overdenture. You say that the office staff told you that this
procedure was covered by your plan. You also say that your $1,000 member benefit should be applied toward
this bill. 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 for the partial
mandibular overdenture (D5866) provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided on February 25, 2020.
You asked the Plan to pay for a knee orthosis. You say that this item meets Medicare guidelines. The Plan denied your request. The Plan says the proof of delivery is absent from the records.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery was not included in the submitted documentation. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) provided on February 25, 2020.