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

We decided that the Plan does not have to pay for the abutment supported porcelain or ceramic crown provided on May 20, 2019.
You asked the Plan to pay for the abutment supported crown. You say that you had a dental implant put in and knew that the crown was covered. You also say that you found out after that you are only covered for repairs of crowns, not new crowns. The Plan denied your request. The Plan says this crown is an implant abutment. The Plan also says that your plan does not allow payment for implant related 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 abutment supported porcelain or ceramic crown provided on May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve behavioral therapy. You say that you feel that this provider was the better choice for your care. The Plan denied your request. The Plan says they have approved office visits with an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve behavioral therapy to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the out of network medical services. You say that the basis of your appeal is
due to your experience seeking care for your urinary signs and symptoms over the past
three years. You say that you repeatedly communicated your concern that your symptoms were indicative of
cancer. You say that the provider never conducted a proper workup for bladder cancer. You say that you were
misdiagnosed by the in network provider you saw. You say that you require care out of network so that you can
proceed with your treatment plan with appropriate confidence, trust, and care. The Plan denied your request.
The Plan says there are multiple experts with experience care for members with bladder cancer at the Medical Center and other regional facilities.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services.
Our decision is in regards to the Plan's requirement to cover the out of network care requested. Your complaint
regarding the care you received from the in network provider is considered a grievance and must be addressed
by the Plan separately. Medicare does not permit us to make decisions about these types of complaints.
Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out
of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient hospital from June 19, 2019 to June 23, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the claim has been paid and the copayment has been 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 $275 copayment per day, for days 1-7 for Medicare-covered hospital services. You have been asked to pay a $1,100 copayment for the acute inpatient hospital admission ($275 x 4). 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 acute inpatient hospital care provided June 19, 2019 to June 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Myocardial perfusion imaging, tomographic (SPECT) (78452, A9500) provided November 21, 2019.You asked the Plan to pay for the Myocardial perfusion imaging. You say that the services were medically necessary and correctly coded.The Plan denied your request. The Plan says the records do not support the codes billed.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 codes 78452 and A9500 are Myocardial perfusion imaging, tomographic (SPECT) and Technetium tc-99m sestamibi, diagnostic, per study dose.We find that CPT codes 78452 and A9500 are not supported in the medical record. Specifically, the records provided do not include reports from the procedure billed. The services cannot be verified by the records provided. Based on this information, we decided that Medicare rules for coverage of the Myocardial perfusion imaging have not been met.Therefore, we decided that the Plan does not have to pay for Myocardial perfusion imaging, tomographic (SPECT) (78452, A9500) provided November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the spinal injection provided on March 6, 2019.
You asked the Plan to waive the deductible for the spinal injection. You say that you were not told that a coinsurance had to paid after your deductible was met. 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. Your contract with the Plan says that there is a $1,000 deductible that applies towards ambulatory surgical center services. The spinal injection you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards ambulatory surgical centers services. The record shows that the spinal injection was provided at an ambulatory surgical center. This cost sharing is a contractual obligation that had not been met at the time the spinal injection was received on March 6, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the spinal injection provided on March 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 13, 2020.
You asked the Plan to pay for the dental service. You say that the x-rays should be covered as it was very close to the 12-month time period. The Plan denied your request. The Plan says bitewing x-rays are covered once every 12 months. The Plan also says the frequency limit 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 bitewing x-rays are a covered services, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on January 15, 2019. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on
February 19, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for fixed partial denture sectioning
(D9120) provided on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 13, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on February 13, 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 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight only in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy can be tolerated or needs to be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 23, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the bill for these services seems excessive as this was not life threatening. The Plan denied your request. The Plan says that your copayment was applied as per your plan benefits.
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 $270 copayment for per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport falls within the ground ambulance trips 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 ambulance transport provided on January 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from November 1, 2019 to November 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 enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 13, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the services rendered from November 1, 2019 to November 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided on January 30, 2020.
You asked the Plan to pay for the dental services. You say that your dentist referred you to see the provider in this case as soon as possible to have your tooth extracted. You say that the provider's office was unable to confirm coverage of the extraction as the Plan's system was down. You say that you did not call the plan for prior authorization, nor after you received the services as you were advised to go to the emergency room and were there overnight. You also say that you would pay for the premium dental rider if that would mean your denial could be overturned. The Plan denied your request. The Plan says extractions are not a covered service. The Plan says there were no calls on record for the date of service from the provider's office. The Plan also says that they are not able to backdate a rider to pay for services that you already received.
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 extraction is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided on January 30, 2020.
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 acute inpatient rehabilitation facility admission is medically necessary.The Plan denied your request. The Plan says that you do not meet criteria for coverage of an IRF admission.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 the complexity of your nursing, medical,and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require skilled physical and occupational therapy; however, you do not require treatment in an intensive rehabilitation therapy program. Additionally, based on the medical records provided, there is concern that you would not be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ECG provided on January 10, 2020.You asked the Plan to waive the copayment foran ECG. You say that the ECG was a pre-operative service and feel that copayment should be waived.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrolleesin 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 copayment for outpatient diagnostic tests. You received an ECG on January 10, 2020.Pre-operative procedures are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for an ECG. An ECG 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 thePlan does not have to waive the copayment foran ECG provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from January 20, 2020 to February 1, 2020.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that these services helped your pain. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
Medicare rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Though the Plan offers a benefit in excess of this coverage, extraspinal manipulation is excluded from this benefit. The records show that the service at issue is extraspinal manipulation, which is listed as not a covered benefit by the Plan. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from January 20, 2020 to February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 29, 2019.You asked the Plan to pay for lab tests. You say that the physician only submitted information to you to link the enrollee's sample to the test requisition.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the necessity of the tests billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The lab requisition form submitted is not a valid physician order because it has not been signed by the ordering provider. Furthermore, medical records from the ordering provider were not submitted that would show a clear intent for ordering these tests. The Plan requested this information, but it was not provided. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 29, 2019.
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 the care required can be provided in the current inpatient hospital 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 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 acute care hospital (ACH) for pneumonia, respiratory failure and encephalopathy. The enrollee's long-term prognosis is unclear. There is no evidence that the enrollee requires services that are not currently available. 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 (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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility services provided April 30 to June 19, 2019.You asked the Plan to pay forthe skilled nursing facility services. You say that the services should be covered as they were medically necessary.The Plan denied your request. The Plan says the enrollee had invoked their hospice benefit at the time the services were provided. Original Medicare is liable for payment forthese services.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 providerto 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 forskilled nursing facility services provided April 30 to June 19, 2019.