Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953).

You asked the Plan to pay for the dental service. You say that the procedure that was performed on the above date was a medical procedure not a dental procedure it was a bone graph. The Plan denied your request. The Plan says bone replacement grafts are specifically excluded from 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.

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 bone replacement graft (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation and two additional intraoral periapical x-rays or pay more for the first intraoral periapical x-ray provided by an OON provider.

You asked the Plan to pay for the consultation and two additional intraoral periapical x-rays or pay more for the first intraoral periapical x-ray. You say that you do not feel you should be held responsible for these charges because you were told the consultation would be free. The Plan denied your request. The Plan says the consultation is not a covered service. The Plan also says that your benefits for the intraoral x-rays had been satisfied and the frequency limitation had 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, the consultation is not among those covered under this benefit. The Plan contract clearly states that intraoral x-rays are limited to one procedure per calendar year, and you must pay a 50% coinsurance when the service is received out-of-network. The record shows that you received three intraoral periapical x-rays, one of which was covered by the Plan at 50%, and your intraoral x-rays benefit had been exhausted. The record shows that you were not given any misinformation when you contacted the Plan. Therefore, we decided that the Plan does not have to pay for the consultation and two additional intraoral periapical x-rays or pay more for the first intraoral periapical x-ray provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99213) provided by an out of network (OON) provider.

You asked the Plan to pay for OON office visits. You say that the enrollee was referred for dermatology services. The Plan denied your request. The Plan says these 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 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 office visits (99213) provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Auto Emersion Therapy Mattress.

You asked the Plan to pre-approve an Auto Emersion Therapy Mattress. You say that the requested Auto Emersion Therapy Mattress is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Auto Emersion Therapy Mattress.

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 an Auto Emersion Therapy Mattress. Our reviewer says that the enrollee does not meet criteria for the requested Auto Emersion Therapy Mattress. Our physician reviewer found the enrollee is a quadriplegic patient with a T4 spinal cord injury from a motor vehicle accident at age twenty. He is requesting coverage for a Durable Medical Equipment, Auto Emersion Therapy Mattress to replace the current mattress due to not being effective. He has developed wounds on his abdomen and buttocks due to lying in bed. He is currently using a low air loss mattress. This mattress is 2 years old and is deteriorating. His wounds are getting worse. His provider has requested coverage for a specific air fluidized bed. The wife provides care. Progress note the enrollee has multiple chronic wounds since age 20 except for a new right lower quadrant abdominal wound from an abscess debrided in the operating room. He has an alternating air mattress. He has a cushion for his wheelchair. He is noted usually in bed. He has a wound vac.

The documentation does not reveal that in the absence of an air-fluidized bed, the enrollee would require institutionalization therefore criteria per National Coverage Determination (NCD) for Air-Fluidized Bed Chapter 1, Section 280.8. have not been 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 an Auto Emersion Therapy Mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve an Auto Emersion Therapy Mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction services (90215).

You asked the Plan to pay for the refraction services. You say that you were told your provider was in network but found out after the bill came that the refraction part was not covered. Now you are responsible for this $48 charge which you feel you should not be responsible for. The Plan denied your request. The Plan says the enrollee must receive vision services from an in-network provider. The enrollee has no out of network benefits to reimburse for the refraction services.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by an in-network provider.

We looked at the file and the Plan's rules. the enrollee must receive vision services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services (90215).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the services.

You asked the Plan to pay for the services. You say that you do not have any other insurance. The Plan denied
your request. The Plan says that the claim must first be submitted to your primary insurance.

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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided documentation showing that you have a separate
primary insurer, resulting in the Plan as your secondary insurer. Without supporting documentation, the Plan's
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services.

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 acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs a stay at the IRF so that he can
regain his strength, endurance, and independence. The Plan denied your request. The Plan says the denial of
authorization for IRF service is correct.

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. While the
record supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a
reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy.

You asked the Plan to waive the copayment for an endoscopy. You say that you disagree with the charges because you feel that you should owe a diagnostic copayment instead. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $40 copayment for specialist visits.

You received an endoscopy at a specialists office. An endoscopy is considered an outpatient surgical procedure. Since services were provided in a specialists office, you are responsible to pay the $40 copayment.

You have been asked to pay a $40 copayment for an endoscopy. An endoscopy falls within the physician/practitioner services, including doctor's office visits 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 an endoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient treatment with an out-of-network tertiary level of care gastroenterology specialist.

You asked the Plan to pre-approve gastroenterology services. You say that you need this provider's expertise to evaluate your condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not need to be treated at the tertiary level of care and can be treated by a community level gastroenterologist instead.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 gastroenterology services. Our reviewer says that you do not meet the Medicare criteria for the requested tertiary level of care treatment. Our physician reviewer found the record does not support a complexity of medical conditions, nor evidence of past inadequate by an in-network community level gastroenterology to require the requested evaluation and treatment at the tertiary level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastroenterology services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient treatment with an out-of-network tertiary level of care gastroenterology specialist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 laboratory services. 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 laboratory services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services.

You asked the Plan to pay for ambulance services. You say that this should be covered. The Plan denied your request. The Plan says coverage of this service is the responsibility of Original Medicare.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

You were under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urinalysis lab test (81000).

You asked the Plan to waive the copayment for the lab test. You say that your lab test should have been covered by the office visit copayment, since that is the reason you have the visit in the first place. The Plan denied your request. The Plan says a lab test is a separate service that is not included in an office visit.

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 $10 copayment for outpatient lab services.

You have been asked to pay a $4.02 copayment for the urinalysis test. The urinalysis test falls within the outpatient lab services benefit category, and is a service separate from an office visit with a physician. 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 urinalysis lab test (81000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Continuous passive motion exercise device (E0935).

You asked the Plan to waive the coinsurance for the Continuous passive motion exercise device. You say that you believed the DME would be covered as part of your home therapy. The Plan denied your request. The Plan says the coinsurance 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 an 18% coinsurance for durable medical equipment (DME), oxygen/ oxygen equipment and related supplies.

You have been asked to pay a total of $95.14 ($528.60 allowed amount x 18% coinsurance = $95.14) for the Continuous passive motion exercise device. This device falls within the Durable medical equipment (DME) and related 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 coinsurance for the Continuous passive motion exercise device (E0935).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the bitewings and prophylaxis provided by an OON provider.

You asked the Plan to pay more for the bitewings and prophylaxis. You say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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, you are responsible for the difference between the billed amount and allowed amount and the 50% coinsurance for each service. Therefore, we decided that the Plan does not have to pay more for the bitewings and prophylaxis provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening tests coded as 87327, 83036, 86021, 86038, 86606, 86612, 86635, 86635, 86698 and 87385.

You asked the Plan to pay for the screening tests. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says screening testing is not a Medicare benefit.

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, the screening tests, 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 screening tests coded as 87327, 83036, 86021, 86038, 86606, 86612, 86635, 86635, 86698 and 87385.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly meets the Medicare criteria for LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.

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 does not require services at the LTACH that are not available at the acute care hospital where she is currently received care. The enrollee is receiving appropriate care at the present acute care hospital. The requested LTACH services are not medically reasonable, necessary, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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.