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

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 19, 2020.
You asked the Plan to pay for the dental services provided on November 19, 2020. You say that these services should be covered. You say that the provider in this case is listed as in network. You say that you used to see this provider before they went out of network. You also say that they are back in network now so 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 that you did not contact them to verify benefits or provider eligibility prior to the date of service.
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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria
are met.
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 these services. Our reviewer says that
the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee does not use a
special drive control and does not meet the criteria for coverage of a power tilt and recline system. There is no
evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer. The
Braden Score indicates he is at mild risk for a pressure ulcer. The requested Group 3 PWC and accessories are
therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Group 3 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 lab work provided on March 11, 2021 by an out-of-network (OON) provider.
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 this level of care is necessary. The Plan denied your request. The Plan says the enrollee's needs can be met outside of the acute hospital setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 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 hyponatremia, confusion and falls. Medical problems are stable.
There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the knee injection procedure and associated Part B drugs you received on April 27, 2021, in your doctor's office.
You asked the Plan to waive the cost sharing for the knee injection procedure and associated drugs. You say that you do not believe this injection procedure should be considered a surgery and that only an office visit copayment should apply. The Plan denied your request. The Plan says you were charged this cost sharing 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 $30 copayment for surgery services in a specialist's office and 20% coinsurance for Part B drugs you receive in a physician's office.
You have been asked to pay a $30 copayment for the knee injection procedure and 20% coinsurance for the associated drugs. Medicare considers this injection procedure to be a surgery. This means that you have been asked to pay the correct amounts 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 cost sharing for the knee injection procedure and associated Part B drugs you received on April 27, 2021, in your doctor's office.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy for Metastases-Bone (Calvarium) by Intensity Modulated Radiation Therapy (IMRT).

You asked the Plan to pre-approve the radiation therapy. You say that please find medical records and physician note which provide evidence as to the medical necessity of radiation therapy treatments. Please re-evaluate this denial determination. The Plan denied your request. The Plan says the records do not show that the enrollee meets the LCD criteria.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found while IMRT may indeed be justifiable in this enrollee, the case files include no quantifiable dosimetric measures. ASTRO model policy emphasizes the need to support IMRT with dosimetry. This would be of particular importance for clinical scenarios for which IMRT is not considered standard. Therefore, the request ss unfavorable for this case as the LCD criteria are 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 the radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy for Metastases-Bone (Calvarium) by Intensity Modulated Radiation Therapy (IMRT).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided 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 in the Medicare rules section. 

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. Based on the enrollee's current medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented acute rehab nursing needs. Functionally as described above at that level, there is no evidence of need for an intensive therapy program with therapy 3 hours per day when she is refusing to participate in therapy with poor endurance and poor activity tolerance with frequent physician oversight and an interdisciplinary approach to rehabilitation care. She has no ability to tolerate an intensive rehabilitation program consisting of at least 3 hours of therapy per day at least 5 days per week, and will not participate and benefit from it. The enrollee's rehab needs can be easily and safely met at a less intense and alternate level of setting such as in a skilled nursing facility if she is willing to participate consistently. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 posterior fillings (D2391) provided on March 5, 2021.
You asked the Plan to pay for the dental services. You say that no one ever told you that your insurance only
covered 2 per year. You say that you feel like you were taken advantage of. You also say that you cannot afford
to pay this bill. The Plan denied your request. The Plan says 2 fillings are covered per year. The Plan says that
the frequency limit has been exceeded. The Plan also says that you did not contact the Plan prior to the date of
service to verify benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for 2 anterior fillings that you received
on the same date of service. Therefore, we decided that the Plan does not have to pay for the 4 posterior fillings
(D2391) provided on March 5, 2021.
Your complaint about feeling like you've been taken advantage of 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: 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 IRF level of care is medically necessary. The Plan denied your request. The Plan says the enrollee does not require this 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 in the Medicare rules section. 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 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 confusion and incontinence and was treated surgically for abscess of the brain. Medical problems
are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 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: 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 IRF care is medically necessary. The Plan denied your request. The Plan says your needs can be met 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 in the Medicare rules section. 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 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 COVID-19 infection and hypoxemia. Medical problems are stable. There are no complex nursing
or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy,
there is no documented need for an intensive, multi-disciplinary 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 26, 2021 by an out-ofnetwork
provider.
You asked the Plan to pay for the office visit. You say that due to the short time period you were unable to get
the authorization before the service was done. The Plan denied your request. The Plan says prior authorization
was not obtained as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 26, 2021 by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup procedure (D2950) provided on March 23, 2021.

You asked the Plan to pay for the core buildup. You say that this service was a necessary part of getting your crown and should be covered. The Plan denied your request. The Plan says this service is not covered by your dental 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 for the core buildup procedure (D2950) provided on March 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay more for the emergency transport (A0427) and ground mileage (A0425) provided on March 11, 2021.

You asked the Plan to pay more for the ambulance transportation services. You say that you used to pay a $50 copay. You say that now you are being billed $300 for a trip to the hospital that is 7 miles away. You also say that this is highway robbery. The Plan denied your request. The Plan says the claim processed correctly with the $300 copayment applied to the ambulance services.

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 $300 copayment for Ambulance Services. 

You have been asked to pay $300 copayment for the ambulance transportation services. The ambulance transportation services fall within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for the emergency transport (A0427) and ground mileage (A0425) provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 28, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay their share for the office visit provided on March 8, 2021 and the electrocardiogram provided on April 8, 2021.
You asked the Plan to pay their share for the office visit provided on March 8, 2021 and the electrocardiogram provided on April 8, 2021. You say that the Plan should pay their share of the claims. The Plan denied your request. The Plan says they have not yet received the primary carrier's explanation of payment for the remaining services.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the office visit provided on March 8, 2021 and the electrocardiogram provided on April 8, 2021. until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay their share for the office visit provided on March 8, 2021 and the electrocardiogram provided on April 8, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 9, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

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 the services was not filed until April 2, 2021. 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 for the services provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care and office visit rendered on March 8, 2021 to March 8, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care and office visit rendered on March 8, 2021 to March 8, 2021.