Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee cannot be adequately cared for in her current condition at a lower level of care.The Plan denied your request. The Plan says the enrollee's care is best managed in the current setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a perforated transverse colon following a recent colostomyreversal. The enrollee has undergone two additional abdominal surgeries. Following the second surgery, the enrollee remained intubated/ventilated and eventually received a tracheotomy. The enrollee remains on a ventilator and appears to have been too ill for any significant weaning trials up to this point. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spinal canal and contents (72148).
You asked the Plan to pre-approve an MRI. You say that this is medically necessary due to the enrollee's increased lower back pain. The Plan denied your request. The Plan says these is no evidence the enrollee has had any conservative treatment for her back pain.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary at this time. Our physician reviewer found the enrollee reports low back pain without history of trauma. There were no complaints of focal neurologic deficits. An examination revealed paraspinous tenderness. Neurologic exam was normal. No history of treatment was included. The enrollee has no red flag findings and there is no cited concern for infection, malignancy or acute or impending neurologic compromise. There has been no trial of conservative 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spinal canal and contents (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on September 13, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this service. 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 this service. Our reviewer says that Medicare coverage criteria were not met. Our physician reviewer found that in this case, the enrollee had no significant condition to warrant monitored anesthesia. There was nothing in this enrollee's record (ASA 2) indicating that it was medically necessary to have an anesthesiologist present during this procedure. Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the bitewings and prophylaxis provided on July 3,
2019.
You asked the Plan to fully pay for the bitewings and prophylaxis. You say that you notified this provider that
you made an insurance change, but you were not notified that this provider was out -of-network. You also say
that you should have been notified of the provider's out-of-network status at that time. The Plan denied your
request. The Plan says that for out-of-network providers, the plan pays according to a maximum allowable fee
schedule, you pay all fees in excess of this amount.
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 Plan says you may be billed by the
out-of-network provider for any amount greater than the payment made by the Plan.
Service Billed Amount Allowed
Amount
Amount Paid
by the Plan
Difference of
Billed & Allowed
Amount
Member
Liability
Bitewings $76 $28 $28 $48 $48
Prophylaxis $110 $46 $46 $64 $64
TOTAL: $112
Therefore, we decided that the Plan does not have to fully pay for the bitewings and prophylaxis provided on
July 3, 2019.
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 admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee does not require services in the LTACH that are not available in the acute care hospital where the member is currently being safely cared for at this time.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 admission. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessaryin this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH. Initially treated for rapid rate atrial fibrillation and heart failure, the enrollee was subsequently treated for bacteremia and cellulitis of the arm. The enrollee is not intubated/ventilated. As LTACHs and 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 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 admission 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe room and board services provided from March 14, 2018 to March 31, 2018.You asked the Plan to pay fortheroom and board services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee enrolled in hospice from March 14, 2018 through April 6, 2018. The plan states, per Medicare guidelines, the provider needs to bill Original Medicare for the services rendered from March 14, 2018 through March 31, 2018.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe room and board services provided from March 14, 2018 to March 31, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement grafts (code D4263 x2) and guided tissue regenerations (code D4266 x2) provided on July 3, 2019.
You asked the Plan to pay for the bone replacement grafts and guided tissue regenerations. You say that you were told that you would not receive any money back because you signed and agreed to pay for the services. You also say that you were told you needed to have gum surgery, accepted the services, and charged $6,000 for the services to your credit card. The Plan denied your request. The Plan says these services are not listed in the limitations and exclusions section. The Plan also says that the provider rendered these services to you at a discounted rate.
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 grafts (code D4263 x2) and guided tissue regenerations (code D4266 x2) provided on July 3, 2019.
Your complaint about not being happy with the dental work done at this dental group is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the radiology services provided on July 30, 2019.
You asked the Plan to pay for the radiology services. You say that you would like the plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the enrollee was on hospice.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that the enrollee was under the federal hospice benefit for the
date of service at issue; however, the Plan has not provided a copy of the MARx screen or hospice election
form to show as fact that the enrollee was enrolled in hospice. This documentation is required by MAXIMUS.
Therefore, we decided that the Plan has to pay for the radiology services provided on July 30, 2019.
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 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 the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH, and is not medically stable.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for an empyema in the setting of recently diagnosed metastatic lung cancer. The enrollee had a chest tube placed and is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and 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 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 admission 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 reimburse the remaining $44 forthe gingival irrigation (D4921), and the drugs or medicaments (D9630 x 2) provided on June 18, 2019.You asked the Plan to reimburse the remaining $44 forthe dental service. You say that the services should be covered. The Plan denied your request. The Plan says the gingival irrigation and the drugs or medicaments are not preventive dental service and therefore are not 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 gingival irrigation and drugs or medicaments are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse the remaining $44 forthe gingival irrigation (D4921), and the drugs or medicaments (D9630 x 2) provided on June 18, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services, lymph system imaging, technetium tc-99m sulfur colloid, excision of a malignant lesion, biopsy or excision of lymph node(s), and injections provided on July 2, 2019.
You asked the Plan to pay for the laboratory services, lymph system imaging, technetium tc-99m sulfur colloid, excision of a malignant lesion, biopsy or excision of lymph node(s), and injections. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services, lymph system imaging, technetium tc-99m sulfur colloid, excision of a malignant lesion, biopsy or excision of lymph node(s), and injections provided on July 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee has no red flag findings concerning for spinal compromise and has not completed an adequate course of conservative care. The current treatment plan is for physical therapy and the results of MRI would not be expected to change that treatment plan. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, anterior resin-based composite, and posterior resin-based composite provided on October 9, 2019 and October 15, 2019.
You asked the Plan to pay for the comprehensive oral evaluation, anterior resin-based composite, and posterior resin-based composite. You say that these services are within the two per year frequency limitations and should be covered by your dental insurance. The Plan denied your request. The Plan says the benefits for these services have been satisfied and the frequency limitations have 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, exams and restorations are each limited to two procedures per calendar year. The record shows that you received exams on January 10, 2019 and January 11, 2019 and your exams benefit was then exhausted. The record also shows that you received 3 fillings on March 22, 2019, the Plan paid for 2 of them, and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, anterior resin-based composite, and posterior resin-based composite provided on October 9, 2019 and October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110),
the bitewing x-rays (D0272), and the initial periapical x-ray (D0220) provided on September 11, 2019.
You asked the Plan to pay for the dental services. You say that you called the Plan prior to receiving the
services. You say that you were advised that you had the DEN975 dental plan and that it is a PPO plan. The
Plan denied your request. The Plan says there is no record of a phone call from you to the Plan prior to the
services being rendered. The Plan says you are 100% liable for services that you receive from a nonparticipating
dentist. The Plan also says that the dentist in this case is not a participating dentist.
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 dental services you received are not
covered as you received them out of network. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0272), and the initial periapical
x-ray (D0220) provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee. You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with an upper GI bleed following recent amputation of her right leg. The enrollee was intubated/ventilated for airway protection, underwent an EGD and subsequently suffered a heart attack. The enrollee only recently received a tracheotomy and is starting to show improved mentation. It has not yet been established that she has failed ventilator weaning. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 19, 2019 and billed under codes 00790 and 99100.
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your request. The Plan says the service itself was approved and the enrollee is being held harmless. The claim is requesting separate payment for code 99100 which is a bundled code. The Plan is unable to approve separate payment for codes bundled into the payment of general anesthetic which the Plan had already approved. The request for additional payment for 99100 is not a covered benefit under the Medicare guidelines. The Plan states the claim itself has a modifier error and requires re-submission. The Plan states several attempts have been made to have a new claim submitted but those requests were not responded to.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and when required the appropriate modifier. Medicare cannot make separate payment for bundled codes. In this case the claim cannot be paid as billed. The Plan has made several attempts to work with the provider for submission of a corrected claim. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on August 19, 2019 and billed under code 00790 and 99100.