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

We decided that the Plan does not have to pay for lab work provided on December 21, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. 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 lab work provided on December 21, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit provided on March 1, 2021.

You asked the Plan to pay for the psychotherapy visit. You say that the enrollee has out of network benefits.
The Plan denied your request. The Plan says the service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently
attempt to enroll in Medicare but are not eligible to do so. A Licensed Master Social Worker is not eligible to
enroll in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the psychotherapy visit have not been met. The record shows this provider is a Licensed Master
Social Worker (LMSW). LMSWs are not eligible to enroll in Medicare which means this provider is not
payable. Therefore, we decided that the Plan does not have to pay for the psychotherapy visit provided on
March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 23, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that Medicare denies coverage for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. The laboratory services provided to the enrollee on October 23, 2020 were not medically necessary or reasonable.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 23, 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 enrollee needs acute monitoring and intensive therapy. The Plan denied your request. The Plan says the enrollee is not able to tolerate an intensive rehab therapy program.

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 physician reviewer found that the enrollee is at a minimal assist level for siting up, supervision for scooting, supervision for walking using a rolling walker, and supervision for dressing and toilet transfers. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and occlusal guard (D9945) provided on March 17, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray and occlusal guard. You say that you did not receive an Annual Notice of Changes for the 2021 Plan year. You also say that you were not aware that your Plan dental services had changed. The Plan denied your request. The Plan says you did not sign up for the comprehensive dental plan.

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 first intraoral periapical x-ray (D0220) and occlusal guard (D9945) provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 based on review of the available records, the enrollee does not meet CMS criteria for IRF admission for debility. The enrollee is medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) physician. She may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on January 28, 2021.

You asked the Plan to pay for the hearing aids. You say that you were given medical clearance for the purchase
of two hearing aids by the doctor at this office. You say that you followed the rules of the insurance plan and
you should be reimbursed. The Plan denied your request. The Plan says the hearing aids were purchased from
an out-of-network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
certain hearing aids only when provided by a network provider.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. The hearing aids were purchased from an out-of-network
provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on January 28,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injectable contraceptive rendered on April 12, 2021.

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 contraceptive services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only.

We looked at the file and Medicare rules. The services at issue are an injectable drug for contraceptive
purposes. This is a preventive service that is not covered by Medicare. Therefore, we decided that the Plan does
not have to pay for the injectable contraceptive rendered on April 12, 2021.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 27, 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 are not covered.

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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and a diagnostic imaging of the retina (92134) provided on October 22, 2019.

You asked the Plan to pay for an office visit and imaging. You say that the claim was submitted within timely filing. The Plan denied your request. The Plan says the original claim processed on November 7, 2019, and the corrected claim was received February 9, 2021. The Plan also says this is past the allowed 12-month timeframe.

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. Corrected and/or adjusted claims are also subject to timely filing.

The record shows that a claim for an office visit and imaging was processed on November 7, 2019, and the corrected claim was received on February 9, 2021. The record also shows that this is past the allowed 12-month timeframe. 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 an office visit (99213) and a diagnostic imaging of the retina (92134) provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites (D2392) provided on March 31, 2020.
You asked the Plan to pay for the resin-based composites. You say that your dentist notified you that you would only pay $79 out-of-pocket. You say that you were never told the service isn't covered under your insurance plan. The Plan denied your request. The Plan says the service is not a covered 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.
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 resin-based composites (D2392) provided on March 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 17, 2021.

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 by an out-of-network provider on February
17, 2021.
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 qualifies for LTACH care
and needs another 3-4 weeks to transition from acute illness. You say that an LTACH is the safest place of
service based on the enrollee's current needs. The Plan denied your request. The Plan says the enrollee does not
meet the guidelines for coverage of LTACH care. The Plan says that the enrollee is not medically stable to
transfer to different level of care. The Plan says that the enrollee has not completed the full course of care in the
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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested
LTACH services have not been shown to be medically necessary, reasonable, and appropriate for the diagnosis
and condition of the enrollee at this time.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires close physician involvement. You say that the enrollee has a qualifying inpatient diagnosis with functional needs that require minimal to moderate assistance. You say that speech therapy is required due to moderate expressive and receptive aphasia and cognitive deficits. You say that the enrollee is able to tolerate the intensive therapy, has means to progress, requires close monitoring, and has a home plan for discharge. The Plan denied your request. The Plan says IRF care 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for stroke and metabolic encephalopathy. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 19, 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 testing is not covered.

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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy rendered on January 29, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $175 copayment for each Medicare-covered outpatient hospital facility visit.

Review of the file shows that you received a diagnostic colonoscopy on January 29, 2021. You have been asked to pay a $175 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility 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 for the diagnostic colonoscopy rendered on January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided on March 13, 20201 and April 13, 2021.

You asked the Plan to waive the coinsurance for the portable oxygen system. You say that you went home from the hospital with the oxygen equipment and didn't know it was a rental. The Plan denied your request. The Plan says you did not return the equipment therefore you were charged the coinsurance 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 10% coinsurance for Durable Medical Equipment. 

You have been asked to pay 10% coinsurance for the oxygen equipment. the oxygen equipment falls within the Durable Medical Equipment 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 oxygen equipment provided on March 13, 20201 and April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the maxillary partial denture - flexible base (D5225) received December 14, 2020.

You asked the Plan to pay an additional amount for the maxillary partial denture. You say that you are unsatisfied with your dentures and do not want to pay for them. The Plan denied your request. The Plan says you have exhausted your $2,000 annual maximum benefit allowance.

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 benefit is limited annually to a maximum of $2,000. Any cost over the $2,000 is your responsibility. On November 19, 2020 the Plan covered a claim in the amount of $262. On November 24, 2020 the Plan covered a claim in the amount of $390. On December 11, 2020 the Plan covered a claim in the amount of $185. On December 14, 2020 you had $1,163 remaining in your annual benefit allowance. On this date of service, you were billed $2,400, and the claim processed with an allowed amount of $1,247, for the maxillary partial denture. The Plan applied the remaining $1,163 towards this claim. Your $2,000 annual benefit allowance exhausted in this claim. You are responsible for the remaining $84 ($1,274 - $1,163 = $84). Therefore, we decided that the Plan does not have to pay an additional amount for the maxillary partial denture - flexible base (D5225) received December 14, 2020.