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

We decided that the Plan does not have to waive the coinsurance for an X-ray of the chest (71046) and a transthoracic echocardiography (93306) provided by an out-of-network provider on November 24, 2020. We also decided that the Plan does not have to pay an MRI scan of the brain (70551) provided on November 24, 2020.

You asked the Plan to waive the coinsurance for an X-ray of the chest and a transthoracic echocardiography and to pay for an MRI scan of the brain. The Plan denied your request.

The Plan says the correct coinsurance was applied to an X-ray of the chest and a transthoracic echocardiography. The Plan also says that rules for payment for an MRI scan of the brain have not been met.

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 20% coinsurance for each X-ray service and other outpatient diagnostic tests when obtained from an out-of-network provider.

You have been asked to pay $16.57, or 20% of the Medicare-allowed charge of $82.85, for an X-ray of the chest, and $99.99, or 20% of the Medicare-allowed charge of $499.93, for a transthoracic echocardiography. An X-ray of the chest and a transthoracic echocardiography fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amounts for an X-ray of the chest and a transthoracic echocardiography 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 coinsurance for an X-ray of the chest (71046) and a transthoracic echocardiography (93306) provided by an out-of-network provider on November 24, 2020.

Medicare rules say that plans may require enrollees to obtain authorization before receiving services. The contract with the Plan says that diagnostic radiology services require prior authorization.

In this case, the Plan did not pre-approve an MRI scan of the brain. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for an MRI scan of the brain (70551) provided on November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
care in an LTACH. You say that the enrollee is stable for transfer. The Plan denied your request. The Plan says
the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee can safely
receive the care needed in the current 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 was admitted to the current acute care hospital with focal status
epilepticus due to missed doses of Keppra requiring intensive care unit (ICU) management. He was
transitioned to Depakote, required mechanical ventilation for acute respiratory failure, and was treated with
intravenous (IV) steroids with some improvement but still not completely alert. He still requires tracheotomy
(trach) and percutaneous endoscopic gastrostomy (PEG) care, IV medications, and physical/occupational
therapies. The enrollee appears to be slowly improving but requires additional short-term acute care services
that can safely be administered at the current facility until stable for a lower level of care. The enrollee does not
require services at the LTACH that are not already available at the current facility. There are no services at the
LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore,
this request for LTACH services will be considered not medically necessary at this time as there would be no
significant clinical benefit to transfer at this time. Transfer may be considered when treatment has completed
and the enrollee is more stable.
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate
lower denture (D5140) provided from April 21, 2021.
You asked the Plan to pay for the dental services. You say that all of your teeth were infected and needed to be
pulled. You say that you needed dentures immediately. You also say that you could not stand the pain anymore.
The Plan denied your request. The Plan says immediate dentures are not listed as covered.
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 immediate dentures are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate
upper denture (D5130) and the immediate lower denture (D5140) provided from April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on October 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. The Plan did not pre-approve the services 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 for the services provided to you by an out-of-network provider on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September
14, 2020.
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your
request. The Plan says the documentation does not support testing for different genetic content on the repeat
test.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the review indicates that the enrollee has advanced non-small cell lung cancer. He underwent Guardant
360 testing x 2 - 9/14/20 and 11/16/20. The documentation did not support testing for different genetic content
on the repeat test. The enrollee did not meet 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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for laboratory services provided to the enrollee on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on May 3, 2021.
You asked the Plan to pay for the re-cement or re-bond crown. You say that you believe re-cementing your tooth was essential and the cost was much less that restoring or removing the tooth. You also say that you have a $500 dental allowance that should be used to cover this procedure. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 re-cement or re-bond crown (D2920) provided on May 3, 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 enrollee will benefit from continued physical
therapy to address her current level of function. You also say that the enrollee will make significant
improvement and will be expected to return home. The Plan denied your request. The Plan says the requested
admission to an IRF does not meet criteria.
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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic images and cone beam CT capture provided on May 10, 2021.
You asked the Plan to pay for the 2D oral/facial photographic images and cone beam CT capture. You say that you stated you only wanted to receive services covered by your insurance and they agreed. The Plan denied your request. The Plan says the services are not covered 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, 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 2D oral/facial photographic images and cone beam CT capture provided on May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a pneumatic appliance (E0673) provided on January 22 to February 18, 2021.
You asked the Plan to pay for an intermittent limb compression device and a pneumatic appliance. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a pneumatic appliance (E0673) provided on January 22 to February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete blood count provided on May 26, 2021 by an OON provider.

You asked the Plan to pay for the complete blood count. You say that the enrollee gets a complete blood count test done once a month for pharmacologic therapy. The Plan denied your request. The Plan says the treating provider is not a network provider with the Plan. The Plan also says that the service was not urgent or emergent in nature, nor was the service approved in advance.

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 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 the complete blood count provided on May 26, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed bridge comprised of porcelain/ceramic retainer
crowns (D6740) and porcelain/ceramic pontics (D6245) spanning from tooth #3 to tooth #6.
You asked the Plan to pre-approve the fixed bridge. You say that this bridge is medically necessary. The Plan
denied your request. The Plan says the records provided show that tooth #3 is present and not missing, and
teeth #4 and #5 are missing. Incorrect coding was submitted for the requested services for teeth #3, #4 and #5.
Unfortunately, even if the correct codes were submitted, more than half of the original bone support on teeth 3
and 6 is no longer present. As a result, a fixed bridge would have a very poor chance of lasting a sufficient
amount of time. For these reasons, the requested for a fixed bridge from tooth #3 to tooth #6 is denied.
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 the fixed
bridge when the services are medically necessary and reasonable.
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 fixed bridge. Our reviewer says that
the bridge requested was submitted with incorrect coding and is not medically necessary due to the condition of
the teeth. Our physician reviewer found the supplied panoramic and bitewing x-rays show that there is 50%
bone loss on the supporting teeth and an unclear amount of bone loss on the surrounding teeth. The proposed
bridge was not coded properly for the teeth present in the upper arch. The present configuration of teeth is not
conducive to a fixed bridge due to the length of the span as well as the periodontal breakdown which
compromises the abutments. Abutments for fixed bridges must have at least 50% bone remaining and have a
reasonable span to replace as the existing root area of the abutments must be sufficient to provide support to the
number of missing teeth. Due to the mis-coding of the teeth present as well as the periodontal condition of the
abutment teeth and the length of the span of the teeth actually present, there would not be medical necessity for
the requested bridge.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does
not have to pre-approve a fixed bridge comprised of porcelain/ceramic retainer crowns (D6740) and
porcelain/ceramic pontics (D6245) spanning from tooth #3 to tooth #6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.

You asked the Plan to pre-approve these services. You say that you have hair loss from undergoing chemotherapy. The Plan denied your request. The Plan says the services are not covered.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, cervical spine (72125) and computed
tomography, head or brain (70450) provided February 13, 2021.

You asked the Plan to pay for the diagnostic services. You say that you are requesting review of the attached
documentation and issue of payment on this claim. The Plan denied your request. The Plan says the services
were paid to another provider.

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 find that payment for these services have already been paid to another provider of the same
group practice or same specialty on check dated March 11, 2021. Based on this information, we decided that
Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan
does not have to pay for computed tomography, cervical spine (72125) and computed tomography, head or
brain (70450) provided February 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services coded as 97150, 99212, S9090 and 98941 provided on May 12, 2021 to May 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you thought that this doctor was in-network and that is why you went to him for chiropractic services. You feel that you should not be responsible for these bills in their entirety. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. 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 the chiropractic services coded as 97150, 99212, S9090 and 98941 provided on May 12, 2021 to May 21, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) supply allowance (K0553), provided on December 18, 2020.
You asked the Plan to pay for CGM supplies. You say that the items should be covered. The Plan denied your request. The Plan says documentation submitted did not sufficiently document the member's medical condition to support the medical necessity for the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) supply allowance (K0553), provided on December 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received on March 25, 2021.
You asked the Plan to waive the copayment for the ER services. You say that you were in the ER for less than an hour and were told there would be a 12-hour wait. You said that the front desk told you that because you were not seen, you would not get a bill. 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 $90 copayment for visits to the emergency room. The medical records from this ER visit show that you were signed in, triaged, and had your vital signs taken and medications reviewed by a nurse. You have been asked to pay a $90 copayment for the ER services. This copayment applies regardless of the extent of services you receive in the ER. 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 room (ER) services you received on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code
81455 are denied as not medically necessary.
We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on March 9, 2021.