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

We decided that the Plan does not have to pre-approveretainer crowns (D6750) for teeth #9, 12, 14, and 15, and pontics (D6240) for teeth #10, 11, and 13.You asked the Plan to pre-approvethe dental services. You say that you are unableto eat. You say that you are afraid to swallow a loose tooth when you are sleeping.The Plan denied your request. The Plan says you do not meet the criteria for the benefit to be allowed.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 dental services when the services are medically necessary and reasonable. We asked our physician reviewer tocarefully 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 dental services. Our reviewer says that the requested bridge is not medically necessary. Our physician reviewer found the provided documentation indicates that there are multiple missing posterior teeth. The reviewer found that the Plan provisions specifically disallow bridgework where there are posterior teeth missing. Given the documentation provided, there can be no medical necessity for the requested bridge under the Plan as there are missing posterior teeth in the upper arch.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 dental services have not been met.Therefore, we decided that the Plan does not have to pre-approveretainer crowns (D6750) for teeth #9, 12, 14,and 15, and pontics (D6240) for teeth #10, 11,and 13
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee would not receive the care she needs at a skilled nursing facility.The Plan denied your request. The Plan says the enrollee would benefit from continued therapy at a lower level of care.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 therelevant 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall and her medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at thisphysician'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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe maxillary partial denture providedon June 24, 2020.You asked the Plan to pay forthe maxillary partial denture. You say that you went to get upper dentures and got billed $150.The Plan denied your request. The Plan says you are responsible for a $150 copayment for dentures which are allowed once every 60 months.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 a $150 copayment for covered complete/partial dentures.Therefore, we decided that the Plan does not have to pay forthe maxillary partial denture provided on June 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric diagnostic services rendered on May 1, 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 filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until November 3, 2020. 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 forthe psychiatric diagnostic services rendered on May 1, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services provided on September 10, 2020 by
an out of network (OON) provider.
You asked the Plan to pay for the OON portable x-ray services. You say that you see enrollees at their homes
and are unable to obtain prior authorization. The Plan denied your request. The Plan says the OON services in
dispute were not urgent, emergent, or 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 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 portable x-ray services provided on September 10,
2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe insertion of stent in urinary duct (ureter) using an endoscope (52332) provided on July 16, 2019.You asked the Plan to waive the coinsuranceforthe insertion of stent in urinary duct. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.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 30% coinsurance for outpatient hospital services. You have been asked to pay a total cost share of $1064.82 for the insertion of stent in urinary duct ($3549.40 allowed amount x 30%coinsurance). The service provided falls within the outpatient hospital 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 coinsurance forthe insertion of stent in urinary duct (ureter) using an endoscope (52332) provided on July 16, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endosteal implant for tooth #12 provided on September 22, 2020.You asked the Plan to pay forthe endosteal implant. You say that you were not advised that your dental rider only covered back molars when you signed up.The Plan denied your request. The Plan says this service is not a covered benefit for this tooth because tooth #12 is a posterior tooth. The Plan also says that only implants for anterior teeth are covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat 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 because tooth #12 is a posterior tooth, and the contract clearly states that only the surgical placement of an implant body to replace a single missing natural anterior tooth is covered.Therefore, we decided that the Plan does not have to pay forthe endosteal implant for tooth #12 provided on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal and microscopic examination of growth (17311, 17312, 17315) provided on September 18, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the removal and microscopic examination of growth. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility before services were rendered.
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 removal and microscopic examination of growth (17311, 17312, 17315) provided on September 18, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient mental health services provided to the enrollee from June 4, 2020 to June 8, 2020.You asked the Planto pay forthe services. You say that you required extensive psychiatric care.The Plandenied your request. The Plansaysyour condition had stabilized.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 it was not expected that you would improve in a reasonable period of time, beyond the dates in question, as you were not showing any dangerousness to self or others, suicidal or homicidal thoughts, auditory or visual hallucinations, and without aggressive behaviors. There were no acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. The health plan's denial of continued inpatient psychiatric services appears 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient mental health services provided to the enrollee from June 4, 2020 to June 8, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient surgery rendered on June 30, 2020.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 10061 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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple.We find that CPT code 10061 is not supported in the medical record. Specifically, there is no documentation of incision and drainage of an abscess. 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 outpatient surgery rendered on June 30, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0651) and appliance (E0667).You asked the Plan to pre-approvea pneumatic compression device (E0651) and appliance (E0667). You say that the requested pneumatic compression device (E0651) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested pneumatic compression device (E0651).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 a pneumatic compression device (E0651) and appliance (E0667). Our reviewer says that the enrollee does not meet criteria for the requested pneumatic compression device (E0651). Our physician reviewer found the enrollee is with a past medical history of hypertension, arthritis and lymphedema. A pneumatic compression device (E0651) has been requested. Based on the medical records provided there is no documentation that the enrollee meets the above NCD and LCD criteria for the requested pneumatic compression device (E0651). The records do not document detailed measurements over time confirming the persistence of the lymphedema.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a pneumatic compression device (E0651) and appliance (E0667) have not been met.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0651) and appliance (E0667)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT colonography (74261).
You asked the Plan to pre-approve a CT colonography. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says this type of testing is not covered as colorectal cancer
screening.
Medicare does provide coverage for preventive colon cancer screenings but specifically excludes CT
colonography from this coverage. The Plan follows this same rule. Therefore, we decided that the Plan does not
have to pre-approve a CT colonography (74261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy provided on July 28, 2020.You asked the Plan to pay forthe endodontic therapy. Yousay that your dentist referred you to an out-of-network provider to have the root canal done.The Plan denied your request. The Plan says this 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 forthe endodontic therapy provided on July 28, 2020
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 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 there are no medical needs requiring inpatient admission or complex nursing or rehabilitation needs. You do not require treatment by multiple therapies and there is not a reasonable expectation that you 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. Specifically, you do not meet the requirements for IRF services. This means the IRF services are not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care provided to the enrollee from February 9, 2021, forward.You asked the Plan to pre-approveinpatient mental health care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 9, 2021, forward as this enrollee was not shown to be a danger to themselves or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors or any treatment required for acute threats of safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care provided to the enrollee from February 9, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 7, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says all services obtained from out-of-network providers require prior authorization except for emergency or urgently needed services when the network is not available and out-of-area dialysis 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 did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on August 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe non-emergency ambulance services (A0428) provided on September 11, 2020.You asked the Plan to waive the coinsurance forthe ambulance services. You say that you do not believe you should be responsible for the cost share due to the nature of the case.The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.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 30% coinsurance for non-emergency ambulance services. You have been asked to pay a total cost share of $73.07 for the ambulance services ($243.58 allowed amount x 30% coinsurance). The services provided fall within the non-emergency 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 coinsurance forthe non-emergency ambulance services (A0428) provided on September 11, 2020
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from August 12 to August 15, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the enrollee met clinical indications for admission.The Plan denied your request. The Plan says that admission was not medically necessary or pre-authorized.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the decision to admit as an inpatient should be based on the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors documented in the medical record. In this case,it has been determined that, given the enrollee's medical condition, it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from August 12 to August 15, 2020.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 toopen the case again, we will send you a letter.