Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography services coded 70450 provided on July 17, 2020.
You asked the Plan to pay for the computed tomography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 70450 for the computed tomography service has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography services coded 70450 provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe prefabricated abutment (D6056) and the abutment supported crown (D6058) provided on September 14, 2020.You asked the Plan to reimburse you forthe dental services. You say that an implant with a crown was your only option. You say that there is not a way to secure a crown without the implant. You say that your booklet does not say that a crown on an implant is not covered. You also say that this is a restorative service.The Plan denied your request. The Plan says the prefabricated abutment is not listed as a covered service. The Plan says that abutment supported crown is not listed as a covered service either.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. The Evidence of Coverage clearly states that if a benefit is not listed in this chart then it is not covered and you will be responsible for 100% of the charges.Therefore, we decided that the Plan does not have to reimburse you forthe prefabricated abutment (D6056) and the abutment supported crown (D6058) provided on September 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventative procedure (D1999) provided on August 27, 2020.You asked the Plan to pay forthe unspecified preventative procedure. You say that you would like this service to be covered based on unforeseen circumstances.The Plan denied your request. The Plan says the service provided is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe unspecified preventative procedure (D1999) provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe services rendered on October 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says that the claim was not filed timely.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 claim was not filed within the 180 day timely filing limit; however, this is not the Medicare timely filing limit. Medicare claims must be filed within one year of the date of service. The file shows that the claim was filed on July 21, 2020; therefore, the claim was filed timely per Medicarerules.Therefore, we decided that the Plan has to pay forthe services rendered on October 9, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided on August 18, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that the hospital arranged this transportation and you were not given a choice.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 $150 copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $150 for these services. 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 forthe ambulance services provided on August 18, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power scooter.
You asked the Plan to pre-approve the power scooter. You say that the scooter you have been using no longer works, and you feel that a new one should be covered. The Plan denied your request. The Plan says there is not sufficient documentation to support that coverage criteria are met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not clearly document a mobility deficit that impairs participation in MRADLs. It is not clearly documented that your mobility needs cannot be met by a walker, cane, or manual wheelchair. It does not appear that your treating physician has placed an order for a power scooter. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a new power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that it is felt that LTACH would be the most appropriate.The Plandenied your request. The Plansaysthere is no need to transfer to LTACH from the current 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a male who was admitted to the current acute care hospital with altered mental status, shaking episode, pneumonia, sepsis, stroke, and respiratory failure requiring intubation, antibiotics, Keppra, and breathing treatments. He currently requires high flow oxygen but remains intubated for airway protection due to aspiration risk.The patient appears to be gradually improving but requires additional short term acute care services of less than 25 days which can safely be performed at the current facility. The patient does not require any services at the LTACH that are not already available at the current facility. Therefore, this request for LTACHservices will be considered notmedically necessary. Ongoing treatment at the current facility is appropriate until the patient is able to be transferred to a lower level of 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you believe authorization should be waived.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medicalservices provided on July 2, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 31, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that due to a change in the patient's insurance, authorization was not obtained.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 careand pre-approved care.The provider in this case is not a network provider with the Plan. 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 forthe medical services provided on July 31, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided July 14, 2020.

You asked the Plan to waive the copayment for the emergency visit. You say that you saw your primary provider after hours service. A CT scan was ordered and the equipment at the emergency room was used but you explained at the receiving desk personnel that this was not an emergency room visit The Plan denied your request. The Plan says the claim was processed and the correct copayment has been applied per the 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 $120 copay for emergency room visits for Emergency care. 

You have been asked to pay $120 copay for emergency room visits for the emergency visit. the emergency visit falls within the Emergency care 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 emergency department visit (99283) provided July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete upper dentures (D5110) and complete lower dentures (D5120).You asked the Plan to pre-approvecomplete upper dentures and complete lower dentures. You say that the items are necessary.The Plan denied your request. The Plan says the covered benefit has been exhausted.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 complete dentures (upper and lower) once every five years. We looked at the file and Medicare rules. You received complete upper dentures and complete lower dentures on March 4, 2020. Based on this information, we decided that the Plan's rules for coverage of complete upper dentures and completelower dentures have not been met.Therefore, we decided that the Plan does not have to pre-approvecomplete upper dentures (D5110) and complete lower dentures (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on July 5, 2020, to July 9, 2020.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the Plan sent you here. You say that you should not have to pay for this. The Plan denied your request. The Plan saysthe correct copayment has been applied.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 $235 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $235 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $940 ($235 x 4 days = $940). An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on July 5, 2020, to July 9, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forlaboratory services provided to the enrollee on July 8, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthatthe diagnoses are not covered, missing, or are invalid.ThePlan must follow Medicare rules. Medicare rules say that services are covered if 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found genomic analyses have led to development of targeted therapies now in several clinical trials, and may enable the discovery of new treatment options. However, biopsy often yields limited tissue, thus hampering tissue-based profiling opportunities. Data regarding circulating tumor DNA (ctDNA) profiling in PDAC during real time clinical practice is limited. ctDNA plasma profiling of pts with advanced PDAC is a feasible alternative method to gather comprehensive genomic data. The review has determined that the enrollee meets the criteria for this testing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Planhas to pay forlaboratory services provided to the enrollee on July 8, 2020.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe dermatology visit you had on July 6, 2020.You asked the Plan to waive the copayment forthe dermatology visit. You say that you thought this copayment would be waived due to COVID-19.The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that the copayment waiver only applies to primary care, behavioral health, and telehealth visits.  It does not apply to specialist visits such as dermatology visits.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 $45 copayment for specialist visits. You have been asked to pay a $45 copayment for the dermatology visit. The dermatology visit falls within the specialist visits benefit category. The Plan's copayment waiver program does not apply to specialty visits. This means that you have been asked topay 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 forthe dermatology visit you had on July 6, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe services rendered to you from April 7, 2020 to June 30, 2020.You asked the Plan to waive the copayments forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayments were 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 $550 copayment per day for days 1-3 for in-network inpatient hospital care. Review of the file shows that you received inpatient hospital services from April 7, 2020 to June 1, 2020. You have been asked to pay a $550 copayment per day for days 1-3 for these services, for a total of $1,650. These services fall within the in-network inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received inpatient hospital services from June 22, 2020 to June 30, 2020. Per the contract withthe Plan, there is a $550 copayment per day for days 1-3 for in-network inpatient hospital care. However, you had met your 2020 maximum out-of-pocket amount with the processing of this claim. The Plan has asked you to pay a total of $1,216 for these services instead of the total $1,650 copayment for three days of inpatient hospital services.
The total amount you have been asked to pay for these services is $2,866. 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 copayments forthe services rendered to you from April 7, 2020 to June 30, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe duplex scan you had on August 5, 2020.You asked the Plan to waive the copayment forthe duplex scan. You say that you should only have to pay your specialist copayment.The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for diagnostic procedures and tests. You have been asked to pay a $50 copayment for the duplex scan. The duplex scan falls within the diagnostic procedures and tests 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 forthe duplex scan you had on August 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on April 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until September 16, 2020. A valid Waiver of Liability (WOL) was not received until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe testing services rendered on April 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless forinpatient care provided from March 3, 2020, to March 24, 2020.You asked the Plan to hold you harmless forinpatient care. You say that you don't understand why these services were denied.The Plan denied your request. The Plan says that these services were not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.The case file indicates that the inpatient care was provided by a contract provider. The file does not show that the Plan provided prior notice that inpatient care would not be covered. Under Medicare rules, this means inpatient care is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmlessforinpatient care provided from March 3, 2020, to March 24, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 8, 2020.
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 the enrollee did not have prior authorization for out of network care.
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 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. 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 out of network physician services provided to the enrollee on January 8, 2020.