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

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 9, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not covered, as it 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 the services was not filed until August 9, 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 laboratory services provided to the enrollee on April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a retainer crown on tooth #28 and tooth #30 (D6740) and a
pontic porcelain/ceramic on tooth #29 (D6245) provided on October 7, 2020.
You asked the Plan to pay for two retainer crowns and a pontic porcelain/ceramic. You say that you do not
agree with the denial of the claim and would like to request reconsideration by resubmitting the claim and
medical records. The Plan denied your request. The Plan says the requested services are 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 retainer
crown on tooth #28 and tooth #30 (D6740) and a pontic porcelain/ceramic on tooth #29 (D6245) provided on
October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the progress notes provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of IRF care. The Plan says that the enrollee's 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 enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke in September 2021 and is currently receiving custodial care with ongoing weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 15, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the member had another insurance as primary payer on this date of service.
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. As the secondary insurer, the Plan cannot be held responsible for the physician's services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on
July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) and prefabricated abutment - includes modification and placement (D6056) provided July 12, 2021.
You asked the Plan to pay for the implant supported crown and prefabricated abutment. You say that these services were unanticipated but necessary for your health. The Plan denied your request. The Plan says you used your full dental benefit prior to these services, and therefore no payment is due.
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 implant supported crown and prefabricated abutment up to the Plan's $1,000 benefit limit for dental restorative services every calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000
dental benefit has been applied to your dental restorative claims prior to the services in question. Therefore, we decided that the Plan does not have to pay for the implant supported porcelain/ceramic crown (D6065) and prefabricated abutment - includes modification and placement (D6056) provided July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency diagnostic (D0140), periapical x-ray (D0220), and 2 fillings (D2391) provided from August 2, 2021, to August 11, 2021.
You asked the Plan to pay for the dental services. You say that you changed dental offices. You say that there was no Korean language service to help you like at your previous dental office. You also say that you cannot pay this bill. The Plan denied your request. The Plan says 2 periodic or emergency diagnostic exams are covered per calendar year. The Plan says that 1 periapical x-ray is covered per calendar year. The Plan says that 2 fillings are covered per calendar year. The Plan says that these frequency limits have 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 are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for emergency diagnostic exams that you received on June 7, 2021, and March 25, 2021. The record shows that the Plan paid for a periapical x-ray that you received on March 25, 2021. The record also shows that the Plan paid for 2 fillings that you received on June 7, 2021. Therefore, we decided that the Plan does not have to pay for the emergency diagnostic (D0140), periapical x-ray (D0220), and 2 fillings (D2391) provided from August 2, 2021, to August 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from March 17, 2021, to March 23, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was updated.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee was admitted to the hospital with shortness of breath. A secondary diagnosis of acute and chronic respiratory failure with hypoxia was listed. There was insufficient support made for this diagnosis, and therefore, the most appropriate DRG for this admission would be 178, respiratory infections and inflammations with CC. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from March 17, 2021, to March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0274) and periodontal maintenance (D4910) provided on July 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a periodic oral evaluation, bitewing x-rays and periodontal maintenance. You say that you have been going to the same dentist for 15 years and believed that under your Plan, you would be covered for up to $500 and the rest would be your responsibility. The Plan denied your request. The Plan says the provider is OON, and you are responsible for all fees billed by the provider in excess of the allowed amount. The Plan also says that there were network providers in the area to provide the services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. The records show the provider billed for a periodic oral evaluation in the amount of $59. The Plan paid the allowed amount of $19, which leaves a liability amount of $40. The records also show the provider billed for bitewing x-rays in the amount of $74. The Plan paid the allowed amount of $26, which leaves a liability amount of $48. The records also show that the provider billed for a periodontal maintenance in the amount of $156. The Plan paid the allowed amount of $58, which leaves a liability of $98. The EOC confirms that if you receive services from an OON provider, you may be billed any amount greater than the payment made by the Plan to the provider. Specifically, you are responsible for the liability amount of $186 ($40 + $48 + $98 = $186). Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing x-rays and periodontal maintenance have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0274) and periodontal maintenance (D4910) provided on July 20, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization care provided from June 24, 2021, to June 28, 2021.
You asked the Plan to pay for the post stabilization care provided from June 26, 2021, to June 28, 2021. You say that the hospital services provided were medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transferred to an in network facility as of June 26, 2021.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post stabilization care provided from June 26, 2021, to June 28, 2021. Our reviewer says that the post stabilization care provided from June 26, 2021, to June 28, 2021, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee was unstable or inappropriate for transfer at any given time. The reviewer found that the documentation shows the enrollee was stable for transfer as of 5:18 pm on June 25, 2021. 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 post stabilization care provided from June 26, 2021, to June 28, 2021, have not been met. Specifically, the file shows that the enrollee was stable for transfer as of 5:18 pm on June 25, 2021. Therefore, we decided that the Plan does not have to pay for the post stabilization care provided from June 24, 2021, to June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy (29826) provided on June 29, 2021.
You asked the Plan to pay for the shoulder arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exits between CPT codes 29826 and 23412
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 29826 is a column II code to column I code 23412. This claim has not been billed with an appropriate modifier to bypass the edit. 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 shoulder arthroscopy (29826) provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift chair purchased on May 13, 2021.
You asked the Plan to pay for a seat lift chair. You say that the Plan should pay for this item. The Plan denied your request. The Plan says this purchase was not authorized and this provider is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. The Plan did not give prior authorization for this purchase and the provider is not a Medicare eligible provider. The Plan contract rules were not followed when purchasing this item. Therefore, we decided that the Plan does not have to pay for a seat lift chair purchased on May 13, 2021
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for continuous positive airway pressure (CPAP) supplies you received on August 17, 2021.
You asked the Plan to pay for the CPAP supplies. You say that this plan is your primary insurer, not your employer's plan. The Plan denied your request. The Plan says that they are not the primary payer- your other insurance is primary. You must submit your claim to your other insurer first. If they deny the claim, it will then be reviewed by the Plan for processing.
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. We agree that the Plan is the secondary insurer here under Medicare rules. However, the Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has failed to take any of the actions listed above that would meet their obligations regarding coordination of benefits. The Plan has not sent the bill for these items to the primary insurer. The Plan has not directed the provider to send the bill to the primary insurer. The Plan has not made provisional payment for these items with the option of submitting the bill for reimbursement to the primary insurer. The Plan has provided no documentation of any of these efforts that would have satisfied this burden. Therefore, we decided that the Plan has to pay for continuous positive airway pressure (CPAP) supplies you received on August 17, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, 83789, G0480) rendered by the out-of-network (OON) provider on July 13, 2021.
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 drug testing services (80307, 83789, G0480) rendered by the out-of-network
(OON) provider on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from July 8, 2021, to
July 12, 2021.
You asked the Plan to pay for the self-administered drugs. You say that some bills were paid in full. You say
that you do not understand what self administrating drugs means. You also say that you do not understand why
your second insurance did not take care of the rest like the other bills. The Plan denied your request. The Plan
says the drugs you received are considered self-administered. The Plan says self-administered drugs are
covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not
covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from July 8, 2021, to July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing of autonomic nervous system function (95923)
provided on August 12, 2021.
You asked the Plan to pay for the testing of autonomic nervous system function. You say that you would like
reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says the
member does not meet LCD criteria for coverage of this testing.
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 of autonomic nervous system
function. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found LCD guidelines advise that most autonomic disorders are
diagnosed clinically, with laboratory formal diagnostic testing playing and adjunctive or confirmatory role.
Testing may also be appropriate to monitor disease progression when there is a change in clinical status, or to
evaluate the patient's response to specific treatment for an autonomic disorder. In this particular case the
member clinically exhibits thin and dystrophic skin with clinical signs of neuropathy. The medical
documentation does not support the necessity for autonomic function testing, CPT code 95923. The member's
diabetic neuropathy was made on a clinical basis, due to physical findings and patient complaints.
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 of autonomic nervous system function have not been met. Therefore,
we decided that the Plan does not have to pay for the testing of autonomic nervous system function (95923)
provided on August 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 10, 2021 and billed under code G0483.
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 submitted claim indicated the specimen was obtained in a lab and use place of service code 81. However, the medical records show the specimen was obtained in the office which would have been place of service code 11.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and place of service codes. In this case, the claim submitted, and the medical records do not show accurate place of service codes were reported.
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pay for lab services provided to the enrollee on June 10, 2021 and billed under code G0483.