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

We decided that the Plan does not have to reimburse you for the crown (D2740), and the labial veneers (D2962 x 2) provided on January 18, 2021.
You asked the Plan to reimburse you for the dental services. You say that you fell while hiking and broke 3 teeth. You say that this is a medical claim. You say that you were told by a plan representative that it was a valid medical claim. The Plan denied your request. The Plan says crown is not listed as a covered service. The
Plan says that labial veneers are not listed as covered services. The Plan also says that routine dental services are not covered by Medicare.
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 crown and labial veneers are not among those covered under this benefit. Additionally, the services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740), and the labial veneers (D2962 x 2) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), crowns for teeth #4, 7, 15, and 19 (D2740), core buildup for teeth #4, 7, 15, and 19 (D2950), gingivectomy or gingivoplasty (D4211), guided tissue regeneration for teeth #16 and 17 (D4266), periodontal scaling and root planing (D4341), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381), and gingival irrigation (D4921).
You asked the Plan to pre-approve a comprehensive periodontal evaluation, crowns for teeth #4, 7, 15, and 19, core buildup for teeth #4, 7, 15, and 19, gingivectomy or gingivoplasty, guided tissue regeneration for teeth #16 and 17, periodontal scaling and root planing, localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, and gingival irrigation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
comprehensive periodontal evaluation (D0180), crowns for teeth #4, 7, 15, and 19 (D2740), core buildup for
teeth #4, 7, 15, and 19 (D2950), gingivectomy or gingivoplasty (D4211), guided tissue regeneration for teeth
#16 and 17 (D4266), periodontal scaling and root planing (D4341), localized delivery of antimicrobial agents
via a controlled release vehicle into diseased crevicular tissue (D4381), and gingival irrigation (D4921).
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 was admitted to an acute care hospital for respiratory failure. The enrollee has been extubated. 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. The elements of the coverage rules are not satisfied.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation (A0427, A0425) provided July 4, 2020.
You asked the Plan to pay for the ambulance transportation. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the enrollee was an inpatient at the time services were provided. Payment is bundled with the inpatient stay.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A0427, & A0425 is not supported in the medical record. Specifically, the record shows the enrollee was an inpatient when the services were rendered. Ambulance transportation during an inpatient stay is considered "patient transportation" and is covered as an inpatient hospital service. It is not separately payable.
Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0427, A0425) provided July 4, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve diastasis recti repair.
You asked the Plan to pre-approve diastasis recti repair. You say that the services are necessary. The Plan
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria
have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 pre-approve diastasis recti repair. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found in this case; the enrollee developed diastasis recti after weight lifting. The diastasis is causing
pain and constipation. It is interfering with maintenance of a healthy lifestyle. Repair is medically necessary
and reasonable as defined by Medicare rules. The elements of the coverage criteria are satisfied. The requested
service is recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of diastasis recti repair have been met. Therefore, we decided that the Plan has to
pre-approve diastasis recti repair.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen
(74150).
You asked the Plan to pre-approve a CT scan of the abdomen. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 pre-approve a CT scan of the abdomen. Our
reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the
record indicates that the enrollee has lost several pounds unintentionally since April. Laboratory tests were
ordered but no further work up. The provided records do not support the medical necessity or reasonableness,
as defined by Medicare rules, of the requested services. The elements of the coverage criteria are not
satisfied. The requested service cannot be recommended at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CT scan of the abdomen have not been met. Therefore, we decided that the
Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen (74150).
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 you need IRF care. The Plan denied your request.
The Plan says rules for IRF care have not been met.
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 that you were admitted for chronic obstructive pulmonary disease exacerbation,
pneumonitis, urinary tract infection and right arm weakness. Medical conditions are stable. There are no
complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. Although you do require physical and occupational therapy,
there is no documented need for an intensive rehabilitation program. Medically necessary services can be
provided in a different level of care. In conclusion, there is not a reasonable expectation that you will be able to
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99334) provided on February 6, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. 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 established patient domiciliary or rest home
visit (99334) provided on February 6, 2021 by an out of network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had on December 31, 2020.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you believe this service should be covered in full because it was preventative. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan also notes that it has reprocessed the claim for the injectable drugs you received, so our decision will not address that service.
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 $250 copayment for outpatient surgery.
Records show that you had a diagnostic colonoscopy as a follow-up from a hospitalization for diverticulitis. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Because this colonoscopy was not performed for screening purposes, it is considered an outpatient surgery. 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 diagnostic colonoscopy you had on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vitamin B-12 injection you received on February 5, 2021.
You asked the Plan to waive the coinsurance for the vitamin B-12 injection.. You say that you cannot afford this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the vitamin B-12 injection. The vitamin B-12 injection. falls within the Medicare Part B drugs 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 coinsurance for the vitamin B-12 injection you received on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the complete upper denture (D5110) and the complete lower denture (D5120) provided on March 5, 2021.
You asked the Plan to waive the copayment for the dental items. You say that you were advised that there was no copayment for dentures. The Plan denied your request. The Plan says there is a $150 copayment for covered dentures, per arch. The Plan also says that the copayment was applied correctly.
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 dentures are listed as covered, there is a $150 copayment for an upper denture and a $150 copayment for a lower denture. $150 + $150 = $300. Therefore, we decided that the Plan does not have to waive the copayment for the complete upper denture (D5110) and the complete lower denture (D5120) provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on January 18, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you had to go back to the provider to have lab work done a second time because it was messed up the first time. You say that you were told there would be no charge for this second lab service. 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 $15 copayment for each for lab test. You have been asked to pay a $15 copayment for each for the lab services. This copayment applies regardless of the reason for the test. 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 lab services you had on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on November 6, 2020.
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you did not know there would be a high cost-share for your surgery. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a 20% coinsurance for outpatient surgery. The allowed amount of the claim is
$15,544, resulting in a coinsurance obligation of $3,108.80. The EOC confirms 20% is the required
coinsurance for this service. 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 coinsurance for outpatient surgery
provided on November 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0426) received January 26, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had COVID and would like the copayment waived. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $325 copayment for Ambulance Services. You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan contract does not provide an exception for Ambulance Service copayments under any circumstances. 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 ambulance transportation (A0425, A0426) received January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient surgical services rendered
on March 19, 2021, and March 26, 2021.
You asked the Plan to waive the copayments for these 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 $90
copayment for outpatient procedures/surgery at an outpatient hospital.
Review of the file shows that you received outpatient surgical services on March 19, 2021, and March 26,
2021.
You have been asked to pay a $90 copayment per date of service for these services, for a total of $180. These
services fall within the outpatient procedures/surgery at an outpatient hospital 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 copayments for the outpatient surgical services rendered on March 19, 2021, and
March 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for mobile cardiovascular telemetry (93229) provided on March 19, 2021.
You asked the Plan to waive the coinsurance for mobile cardiovascular telemetry. You say that your monitor may have been defective. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each Medicare-covered diagnostic procedure or test. You have been asked to pay $120, or 20% of the Medicare-allowed charge of $600, for mobile cardiovascular telemetry. Mobile cardiovascular telemetry 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 coinsurance for mobile cardiovascular telemetry (93229) provided on March 19, 2021.