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

We decided that the Plan does not have to pay for the laboratory services rendered on January 23, 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 must follow Medicare rules. The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 88112 once with the -26 modifier and once without a modifier. The Plan allowed the billing of the global service without the modifier. Code 88112 does not meet the criteria for payment with the -26 modifier. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveunlimited non-emergency medical transportation (T2003).You asked the Plan to pre-approveunlimited transportation. You say that you get arthritis injections twice a month and sometimes three times a month.The Plan denied your request. The Plan says this request exceeds the benefit limitationMedicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveunlimited non-emergency medical transportation (T2003).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a skilled nursing facility level of care. A less intensive, longer duration of therapy is appropriate. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay on December 17, 2019 to December 28, 2019.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you thought that your
insurance would cover the cost of this. You say that you cannot afford this copayment. 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). Your contract with the Plan clearly says that you must pay a $0
copayment per day for days 1-20. There is a $170.50 copayment for days 21-100 for skilled nursing facility.
You have been asked to pay a $0 copayment per day for days 1-20. There is a $170.50 copayment for days 21-
28 for a skilled nursing stay. The total amount you are being asked to pay is $1,193.50 ($170.50 x 7 days =
$1,193.50). A skilled nursing stay falls within the skilled nursing facility 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 a skilled nursing stay provided by a participating facility on
December 17, 2019 to December 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 20, 2020 by a noncontracted 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-contracted 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 March 20, 2020 by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

e decided that the Plan does not have to pre-approve core buildup  for teeth 8 and 9 (D2950).You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration of the denied services. A crown must be placed to build back tooth structure for the overall dental health of the enrollee.The Plan denied your request. The Plan says this service is not covered under the 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve core buildup  for teeth 8 and 9 (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 16, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. You say that these services are provided in good faith. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the facility is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 skilled nursing services provided on October 16, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNFservices.You asked the Plan to pre-approvecontinuation of SNF services. You say that the enrollee is in pain and still needs care and cannot be on her own. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines because the enrolleeno longer requires skilled services and the continuation of SNF is not medically necessary.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 the continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found the enrollee does not require skilled nursing services. Based on available records, the enrollee does not meet criteria for coverage of SNF. The records do not support that the enrollee needs continued daily physical therapy (PT) and occupational therapy (OT). There are no noted daily skilled complex nursing needs. While she is expected to benefit from continuing PT and OT, the records do not support the need for daily therapy.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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by an out-of-network provider on January 13, 2020.
You asked the Plan to waive the deductible for an outpatient surgery. You say that this should be in-network and not out-of-network. The Plan denied your request. The Plan says the correct deductible has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for outpatient surgery. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time an outpatient surgery was received on January 13, 2020. The remaining deductible is $574.91. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient surgery provided by an out-of-network provider on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sinus augmentation (D7951) of the upper right quadrant, surgical placement of implant body: endosteal implant (D6010) for tooth #3, custom fabricated abutment (D6057) for tooth #3, and an abutment supported porcelain/ceramic crown (D6058) for tooth #3.
You asked the Plan to pre-approve the sinus augmentation, endosteal implant, custom fabricated abutment, and abutment supported crown. You say that you are unable to eat on your right side. The Plan denied your request. The Plan says the sinus augmentation is not a covered benefit. The Plan also says that the endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown are not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the endosteal implant, custom fabricated abutment, and abutment supported crown when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported crown. Our reviewer says that placing an implant to replace tooth #3 is neither medically reasonable nor necessary. Our physician reviewer found other methods of replacing the missing maxillary teeth appear to be more beneficial to restoring the patient's masticatory function. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the endosteal implant, custom fabricated abutment, and abutment supported crown have not been met. The contract also does not list sinus augmentation as a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a sinus augmentation (D7951) of the upper right quadrant, surgical placement of implant body: endosteal implant (D6010) for tooth #3, custom fabricated abutment (D6057) for tooth #3, and an abutment supported porcelain/ceramic crown (D6058) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and extracoronal provisional splinting provided on December 6, 2019 and December 17, 2019.
You asked the Plan to pay for the first intraoral periapical x-ray and extracoronal provisional splinting. You say that you would like to be reimbursed for these charges. The Plan denied your request. The Plan says these services are not covered 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 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 first intraoral periapical x-ray and extracoronal provisional splinting provided on December 6, 2019 and December 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory infectious agent detection (CPT 87633) provided to the enrollee on December 16, 2019.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 this is non-covered and excluded from coverage.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 services at issue in this case were not medically reasonable or necessary. Our physician reviewer found without clinical records, it cannot be determined that the respiratory infectious agent detection (CPT 87633) provided on 12/16/19 were medically reasonable and necessary for the enrollee 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 the services have not been met.Therefore, we decided that the Plan does not have to pay for respiratory infectious agent detection (CPT 87633) provided to the enrollee on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea powered upper extremity range of motion assist device.You asked the Plan to pre-approvea powered upper extremity range of motion assist device (L8702). You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living.The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered. We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. The requested limb orthosis continues to be deniedbecause of insufficient evidence of its effectiveness.Therefore, we decided that the Plan does not have to pre-approvea powered upper extremity range of motion assist device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on January 8, 2020.You asked the Plan to pay for. The Plan denied your request. The Plan says screening tests 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 lab services at issue in this appeal were 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 forthe lab services provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 23, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrolleemust 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 physician's 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 physician's services provided on October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on November 20, 2019 and November 24, 2019.
You asked the Plan to waive the copayments for the ambulance rides. You say that you live on a very small income and would like these claims removed or reduced. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $200 copayment per one-way trip. You have been asked to pay a $200 copayment for the ambulance ride on each date of service. The ambulance rides fall within the "Ambulance 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 copayments for the ambulance rides provided on November 20, 2019 and November 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 9, 2019. 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoe lift. You asked the Plan to pre-approve a shoe lift (L3310). You say that you need a shoe lift because of leg length discrepancy. The Plan denied your request. The Plan says this item is not a covered benefit. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve a shoe lift.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebone marrow aspiration for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this procedure is helpful for treatment of the enrollee's health problem.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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental in spinal surgery. More research is needed to show safety and efficacy.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 procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvebone marrow aspiration for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient surgery provided by a participating provider on October 17, 2019.You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. 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). Your contract with the Plan clearly says that you must pay a $325 copayment for outpatient surgery/outpatient hospital facility visit. You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/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 an outpatient surgery provided by a participating provider on October 17, 2019.