Persius/hicric huggingface dataset:
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that 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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional test strips provided on December 21, 2020.
You asked the Plan to pay for the test strips. You say that additional test strips are needed because you are a brittle diabetic. The Plan denied your request. The Plan says you received more than the plan allows.
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 there is a limit of 100 test strips per 30-day supply. We looked at the file and the rules. In this case, there are no records from your provider indicating that additional tests strips were necessary for your testing. The additional test strips were not pre-approved by your plan. The test strips fall within the diabetes self-management, services, and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the additional test strips provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from December 25, 2019 to December 30, 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 the medical records do not support the billed DRG and diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 689 and diagnosis code J18.9 (pneumonia, unspecified organism). 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 these services. Our reviewer says that the medical records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee received an initial x-ray on December 25, 2019 that indicated atelectasis/infiltrate in the left lower lobe and the follow-up x-ray on December 28, 2019 noted only mild plate-like atelectasis. There is insufficient objective clinical evidence to validate the diagnosis of pneumonia. The Plan was correct in its decision to remove code J18.9. The records do not support the billing of diagnosis code J18.9. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from December 25, 2019 to December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frames (V2025) purchased on December 30, 2019.
You asked the Plan to pay for the frames. You say that you have not received payment from this benefit and do not understand how it could have been exceeded for the date in question. The Plan denied your request. The Plan says that up to $100 of the retail price for frames and eyeglasses is covered each year. You are responsible for any amount that exceeds this $100 maximum. The Plan reimbursed you for the allowed $100 on January 24, 2020, and you are responsible for the remaining cost for the frames. The remaining cost exceeded the Plan's benefit allowance.
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 up to $100 of the retail price for one purchase of eyewear per calendar year. We looked at the file and the Plan's rules. Documentation shows that this claim was updated in January of 2020 to reimburse you $100 for the frames. This is the maximum amount allowed for eyeglasses in one calendar year. Therefore, we decided that the Plan does not have to pay an additional amount for the eyeglass frames (V2025) purchased on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), the gingival irrigation (D4921 x 4), the treatment of a root canal obstruction (D3331), and the pulp vitality test (D0460) provided from January 19, 2020, to January 25, 2021.
You asked the Plan to pay for the consultation, gingival irrigation, treatment of a root canal obstruction, and the pulp vitality test. You say that you thought the providers assigned to you were in network. You also say that you cannot afford to pay for this bill. The Plan denied your request. The Plan says the consultation, gingival irrigation, treatment of a root canal obstruction, and the pulp vitality test are not listed as covered 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, 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 consultation (D9310), the gingival irrigation (D4921 x 4), the treatment of a root canal obstruction (D3331), and the pulp vitality test (D0460) provided from January 19, 2020, to January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the mattress (A9270) and the adjustable base protection plan (A9270) provided on July 22, 2020.
You asked the Plan to issue reimbursement. You say that the items provided are medically necessary. The Plan denied your request. The Plan says these items are not payable under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. We looked at the case file and Medicare rules. Based upon this information, we find that your request does not meet Medicare criteria. Specifically, the mattress and adjustable base protection plan were purchased without a prescription from your treating physician to support medical necessity. This is not a hospital grade mattress and was purchased without prior approval from the Plan. Additionally, the items were purchased from a retail store and not a Medicare DME provider. Therefore, we decided that the Plan does not have to issue reimbursement for the mattress (A9270) and the adjustable base protection plan (A9270) provided on July 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the co-payment for the low dose CT scan provided on January 20, 2021.

You asked the Plan to waive the co-payment for the low dose CT scan. You say that this was to be a preventive scan of the lungs to be done annually and there should be no co-payment. The Plan denied your request. The Plan says that the co-payment applied correctly.

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 enrollees pay a $0 co-payment for a low dose CT scan screening for lung cancer.

The Plan says you must pay a $77.02 co-payment for the CT scan. Based on the Plan contract, however, you cannot be asked to pay more than a $0 co-payment for the low dose CT scan. The records show a low dose CT scan for lung cancer screening was billed. There was no documentation submitted to support the co-payment for a regular CT scan should apply. Therefore, we decided that the Plan has to waive the co-payment for the low dose CT scan provided on January 20, 2021.

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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-UM test provided to the enrollee on October
27, 2020.
You asked the Plan to pay for the test. You say that this test is covered by Medicare. The Plan denied your
request. The Plan says this is not medically necessary.
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 test. Our reviewer says that the requested
services are not considered medically reasonable and necessary in this case. Our physician reviewer found
there is no evidence to support that the provided services were medically necessary and reasonable to diagnose,
treat or otherwise manage the enrollee's condition(s).
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 test have not been met. Therefore, we decided that the Plan does not have to
pay for the DecisionDx-UM test provided to the enrollee on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided January 12, 2021.

You asked the Plan to pay for the post and core for a crown. You say that you were able to save the crown by getting a bigger post and it should be covered since it saved money to do so. The Plan denied your request. The Plan says this service is only covered when you also get a crown.

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 post and core for a crown when the service is performed together with a crown. 

We looked at the file and Medicare rules. The record shows that you did not get a crown when the service was performed. Based on this information, we decided that the Plan's rules for coverage of the post and core for a crown have not been met. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) provided January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast reduction services provided on September 21, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says reconstructive surgery for the purpose of cosmesis is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a reduction mammaplasty is only covered under certain medical indications. We looked at the file and Medicare rules. In this case, there are insufficient medical records to show the enrollee meets the coverage requirements for the surgery. The file shows the plan made multiple attempts to obtain medical records, with no success. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the breast reduction services provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided on January 13, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says there are in network dentists available.
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 and the services are listed as covered, the requested items or services are not among those covered under this benefit when performed out of network. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided on January 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the esophagus biopsy provided on November 5, 2020.
You asked the Plan to waive the coinsurance for the esophagus biopsy. You say that you met your maximum out-of-pocket in October and should not be charged. The Plan denied your request. The Plan says the copayment 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 $360 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $270.15, which is less than the standard $360 copayment because you met your maximum out-of-pocket. The esophagus biopsy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 esophagus biopsy provided on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram (77066) provided November 30, 2020.

You asked the Plan to waive the copayment for the diagnostic service. You say that you have not had a breast screening in the last year and believe this should be covered and no charge to you. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 copayment for most X-rays and ultrasounds. 

You have been asked to pay $10 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for the diagnostic mammogram (77066) provided November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on November 9, 2020.

You asked the Plan to pay for the bone replacement graft. You say that you believe the bone graft should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 for ridge preservation (D7953) provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on July 28,
2020.
You asked the Plan to pay for the dental service. You say that you had a hard time finding an in-network
dentist in your area due to Covid-19. You say that this was an emergency. You say that you needed to be seen
by a dentist and the services should be covered. The Plan denied your request. The Plan says emergency oral
evaluation problem focused exams covered once every 12 months. The Plan says that the frequency limit for
this service has 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 and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for the emergency oral evaluation that
you received on January 22, 2020. Therefore, we decided that the Plan does not have to pay for the emergency
oral evaluation (D0140) provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received on December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 provided by an in-network provider. We looked at the file and the Plan's rules. You were provided the vision services by an out-of-network provider. The Plan does not covered out-of-network routine vision services. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services you received on December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power chair lift purchased from a provider not certified with Medicare.
You asked the Plan to pay for power chair lift. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says while you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that a provider must be certified with Medicare in order to receive payment. We looked at the file and Medicare rules. The case file indicates that the provider in this case is not certified with Medicare. Based on this information, we decided that Medicare rules for coverage of power chair lift have not been met. Therefore, we decided that the Plan does not have to pay for power chair lift purchased from a provider not certified with Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the maxillary partial denture provided on November 5,
2020 by an OON provider.

You asked the Plan to pay in full for the maxillary partial denture. You say that you believe this service should
be covered in full. The Plan denied your request. The Plan says this service was performed by a nonparticipating
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. Therefore, we decided that the Plan does not have to pay in
full for the maxillary partial denture provided on November 5, 2020 by an OON provider.