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

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.  

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 were not billed correctly.  

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 8, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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. Cardiovascular risk assessment panels are only covered for certain indications.

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 7, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that you had to go to an out of network dentist as there are no in-network dentist nearby in your area, and the closest one is 115 miles away from your house. The Plan denied your request. The Plan says the procedure code is not listed and therefore is not covered by 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. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services rendered on August 4, 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 procedure code 00794 is not supported.  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 code 00794 is anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; pancreatectomy, partial or total (eg, Whipple procedure).  We find that CPT code 00794 is not supported in the medical record. Specifically, the records show that the anesthesia services were not performed for an intraperitoneal procedure in the upper abdomen. 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 anesthesia services rendered on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on August 17, 2021.  

You asked the Plan to pay for the topical application of fluoride varnish. You say that you thought Medicare was responsible for paying for preventive services and you thought this service was preventive. You also say that you were not advised at the time of application that this was not a covered service. The Plan denied your request. The Plan says this is not a covered service under your plan. 

 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for an outpatient facility visit provided on July 30, 2021.  You asked the Plan to waive the copayment for an outpatient facility visit. You say that you have only ever paid a $10 copayment for laboratory services in the past and were never charged a facility fee. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.  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 claim shows that only laboratory services took place and that the provider did not bill for an outpatient hospital facility visit. Furthermore, the Plan did not provide any further documentation showing why they processed the claim with an outpatient hospital facility visit charge when the provider did not bill for one. Therefore, we decided that the Plan has to waive the copayment for an outpatient facility visit provided on July 30, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the maxillary immediate denture (D5130) and mandibular immediate denture (D5140) provided on June 29, 2021.  You asked the Plan to pay for the immediate dentures. You say that your plan is supposed to cover a complete set of dentures with a 50% coinsurance. You also say that when you called member services you were assured that the claim would go through. The Plan denied your request. The Plan says these services are not covered by the Plan. The Plan also says that you were advised during your call with the Plan on June 2, 2021 that dentures are not a covered benefit under your policy.  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 maxillary immediate denture (D5130) and mandibular immediate denture (D5140) provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special anesthesia service rendered on January 18, 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 separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia service rendered on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assistant surgeon services rendered on April 7, 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 provider type is not covered.  The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).  We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit for the enrollee.  

You asked the Plan to pre-approve Retacrit. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there are no reported iron studies.  

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   

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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary for the enrollee. There is a lack of documentation submitted regarding iron status. The iron status may be good, but there has not been documentation of iron status that can be found in the record. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Retacrit.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 2, 2021.  You asked the Plan to pay for the dental service. You say that you advised the dental office that you only wanted to receive services that would be covered. You say that the dentist should have coded this service differently. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 years. The Plan also says that 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 the services is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on July 3, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 2, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.  

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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) and immediate maxillary denture (D5130) provided on July 26, 2021.  

You asked the Plan to pay for the removable prosthodontic procedure and immediate maxillary denture. You say that you were advised that after January 1, 2021 your Plan would pay for an upper denture. You also say that you did what you were told and do not understand why these services were not paid by the Plan. The Plan denied your request. The Plan says the removable prosthodontic procedure is not a covered expense under your dental plan. The Plan also says that your dental maximum has been met.  

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 unspecified removable prosthodontic procedure (D5899) is not among those covered under this benefit. The contract says that the Plan offers an annual maximum dental allowance of $2,000. The record shows that you met the annual maximum benefit on July 27, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) and immediate maxillary denture (D5130) provided on July 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and copayments for outpatient rehabilitation services provided from June 28, 2021, to August 19, 2021.  You asked the Plan to waive the deductible and copayments for outpatient rehabilitation services. You say that you disagree with the denied charges because the outpatient rehabilitation services have been really helpful and you are learning how to function the correct way. 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 enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $590 deductible which applies to outpatient rehabilitation services. Your contract with the Plan also clearly says that after the $590 deductible has been met, enrollee's must pay a $25 copayment for outpatient rehabilitation services.   The record shows that you received outpatient rehabilitation services from June 28, 2021, to August 19, 2021. The record shows that you had only paid $59.32 toward the $590 deductible prior to receiving the services. Now that the $590 deductible has been met, you are also responsible to pay the total copayment amount of $50.   The total amount you owe is: $580.68.   The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $590 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time outpatient rehabilitation services were received on June 28, 2021 to August 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible and copayments for outpatient rehabilitation services provided from June 28, 2021, to August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601), supplies (A999), and special service (99199), provided on July 6, 2021.  You asked the Plan to pay for the CPAP device, supplies and special service. You say that the item was medically necessary. The Plan denied your request. The Plan says you obtained this item through a provider that is not enrolled with Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device (E0601), supplies (A999), and special service (99199), provided on July 6, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.  

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74176) provided on September 30, 2021.  

You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you should have been told in advance about the copayment for the services at issue. The Plan denied your request. The Plan says the correct copayment was 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 $200 copayment for each advanced imaging service.   

You have been asked to pay a $200 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74176) provided on September 30, 2021.  

Your complaint about not being forewarned by the provider about your cost-sharing responsibilities 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical extraction (D7210) and bone replacement graft (D7953) provided on August 17, 2021.  You asked the Plan to pay for the dental services. You say that you were directed to this dental office by a plan representative. You say that you were advised that you tooth needed to be extracted. You say that now you are being advised that the dentist you saw is out of network. You also say that this should be covered. The Plan denied your request. The Plan says the surgical extraction is not listed as a covered service. The Plan says that bone replacement graft 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 surgical extraction and bone replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) and bone replacement graft (D7953) provided on August 17, 2021.