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

We decided that the Plan does not have to waive the copayment for audiologic function test (92557) provided October 25, 2019.You asked the Plan to waive the copayment foraudiologic function test. You say that you saw a doctor that uses those facilities and now you have two separate copays for the same service on the same date. You should only have to pay one copay for the one service on that day.The Plan denied your request. The Plan says this claim processed correctly towards the hearing exam benefit.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $15 copayment foreach diagnostic hearing exam to treat disease and condition of the ears. for Hearing services.You have been asked to pay $15 copayment. Audiologic function test falls within the Hearing services 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 foraudiologic function test(92557) provided October 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to pay for TAVR (33361) provided on January 10, 2019.You asked the Plan to pay for the TAVR. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the clinical trial number was not billed on the claim.The Plan must follow Medicare rules. Medicare rules say that contractors shall pay TAVR claim lines for 33361 when billed with the numeric, 8-digit clinicaltrials.gov identifier number.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TAVR have not been met. Specifically, the submitted claim has been submitted with an invalid clinical trial number. The clinical trial number is an 8-digit identifier number specified on clinicaltrials.gov. Therefore, we decided that the Plan does not have to pay for TAVR (33361) provided on January 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on June 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were provided before the end of the month.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on June 6, 2019. The services in question were provided before the end of that month.Therefore,we decided that the Plan does not have to pay forthe services provided to the enrollee on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee requires an inpatient stay with close physician supervision.The Plan denied your request. The Plan says the enrollee would not be able to participate in intensive rehab.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 physician reviewer found that the enrollee was admitted to the acute hospital with uncontrolled diabetes and hypertension. The enrollee was medically managed, and improved. 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 is at minimal to standby assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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 thePlan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on September 24, 2019.
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 pathology 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 pathology services provided on September 24, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET scan.
You asked the Plan to pre-approve the PET scan. You say that the enrollee has been actively monitored and treated for lung adenocarcinoma since 2018. She most recently has been getting treatment with Opdivo but has been in and out of the hospital with shortness of breath and other complicating factors. You are requesting a PET scan to evaluate current lung adenocarcinoma and to see if she is a candidate for oral therapy to improve her quality of life. The Plan denied your request. The Plan says that the enrollee does not meet National Coverage Determination (NCD) criteria as she has had four PET scans for subsequent tumor management.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 PET Scan. Our reviewer says that the enrollee meets criteria for coverage of a PET scan. Our physician reviewer found that while the enrollee has had more than the Nationally covered number of PET scans for her diagnosis of adenocarcinoma of the lung, she also has had an abnormal conventional computed tomography scan (CT Scan) of the chest on February 20, 2020 which questioned advancing metastatic disease within the chest versus inflammatory changes. This abnormal scan combined with the enrollee's comorbidity of significant heart disease gives a valid indication to determine if a change in therapy would be in her best interest and therefore, should be approved under the local Centers for Medicare and Medicaid Services (CMS) covered guidelines rather than the nationally covered limit of three scans. 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 PET Scan have been met. Therefore, we decided that the Plan has to pre-approve a PET scan.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing rendered on August 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0480 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0480 is definitive drug testing, 1-7 drug classes.We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation does not contain results of definitive drug testing of 1-7 drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe definitive drug testing rendered on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on April 2, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have beenbilled with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on April 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bicalutamide for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The Plan denied your request. The Plan says that this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Bicalutamide for the enrollee.
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for thediagnosis 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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, surgical and skin wound care, epoetin alfa injecitons, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), the bitewing x-ray (D0270), and the surgical extraction (D7210) provided on May 15, 2019.
You asked the Plan to pay for the dental services. You say that you had previously contacted the Plan at the end of March 2019 to get a list of in network providers. You say that you chose a provider off of the list. You also say that the provider's office did not inform you of any problems with your insurance nor that they were not in network. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services that you receive out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that are received out of network are not covered. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), the bitewing x-ray (D0270), and the surgical extraction (D7210) provided on May 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the resin-based composite on tooth #11 provided on October 14, 2019.
You asked the Plan to waive the coinsurance for the resin-based composite. You say that this is an incorrect charge because tooth #11 was not repaired. The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits.
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 contract clearly states that you are responsible for a 20% coinsurance for resin-based composites. Therefore, we decided that the Plan does not have to waive the coinsurance for the resin-based composite on tooth #11 provided on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says continued management can be provided in the acute care hospital until that level of care is no longer necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with intermittent BiPAP and oxygen supplementation, intravenous antibiotics, surveillance laboratory studies, and intense therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on October 7, 2019.You asked the Plan to pay forthe services. You say that you thought this was an in-network provider.The Plan denied your request. The Plan says out-of-network services are not covered.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on October 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee has not had a change in function that requires daily skilled services to be provided on an inpatient basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our physician reviewer found that the enrollee is at standby assistance for ambulation and upper body activities of daily living, and minimal assistance for lower body activities of daily living. The enrollee requires oversight of his medical conditions and medication management including medication adjustments. He also requires physical therapy for progression of his mobility, and occupational therapy for remaining activities of daily living. However, the skilled needs do not need to be provided on a daily basis. The enrollee's condition would not be expected to deteriorate with services provided on a less than daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for laboratory testing. You say that this testing was ordered by the treating physician as medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 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 November 21, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered to you on
August 2, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were part of a routine
physical. 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 $20
copayment for Medicare-covered laboratory tests.
Review of the file shows that you received lab services on August 2, 2019. These services fall outside of the
scope of an annual physical exam. Per your contract with the Plan, there is a $20 copayment for Medicarecovered
laboratory tests. This cost sharing is a contractual obligation you agreed to pay when you enrolled in
the Plan. However, the Medicare allowed amount for these services was $18.50. Given that the allowed amount
was less than the $20 copayment, you have been asked to pay $18.50 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered
to you on August 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 to December 26, 2019 by an out of network (OON) provider.
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 were rendered by a non-network provider without prior authorization.
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 December 16, 2019 to December 26, 2019 by an out of network (OON) provider.