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

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), intraoral x-ray (D0220) and bitewing x-ray (D0270) provided on March 25, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that this was an emergency dental visit while you were visiting family out-of-state. The Plan denied your request. The Plan says limited oral exams are not covered under any circumstances. The x-rays have been covered, however because these services were received out-of-network, you are responsible for 50% coinsurance. The provider may also bill you for any amount billed that exceeds the payment made by the Plan. Your benefits were 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. The Plan can cover periodic, periodontal, and comprehensive oral exams. The Plan can cover bitewing and intraoral x-rays. 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 50% coinsurance when you receive these x-ray types from an out-of-network provider. In addition, you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested limited oral evaluation is not among those covered under this benefit, regardless of the circumstances or provider status. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 25, 2021, by an out-of-network provider.

The Plan paid $12 for the two x-rays provided on March 25, 2021. The provider billed a total of $69 for the two services. The Plan's total allowed amount for both x-ray services is $24. You are responsible for 50% of the cost of dental x-rays provided out-of-network. ($24 x 50% coinsurance = $12). Because the provider in question is out-of-network, they are also allowed to bill you for the difference between the Plan's allowed cost for these services and the total amount they billed for the services. ($69 - $24 = $45). 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 pay an additional amount for the intraoral x-ray (D0220) and bitewing x-ray (D0270) provided on March 25, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 10, and a retainer crown (D6740) for tooth # 9.
You asked the Plan to pre-approve the dental services. You say that the enrollee's previous bridge was failing. You say that the enrollee's tooth # 9 was extracted 5+ years ago. You also say that the bridge will restore oral form and function due to the premature loss of the permanent tooth. The Plan denied your request. The Plan says tooth # 9 is missing and not present. The Plan also says that the crown for tooth # 10 is not medically necessary.
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 dental services 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 dental services. Our reviewer says that the requested crowns are not medically necessary. Our physician reviewer found the provided documentation indicates that tooth # 9 is missing and therefore cannot be restored with a crown. The reviewer found that the provided documentation also indicates that tooth # 10 does not have significant breakdown that would require a crown. Therefore, the reviewer found that the requested crowns are not medically reasonable or necessary. 
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 dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 10, and a retainer crown (D6740) for tooth # 9.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for screening mammography, including computer-aided
detection (CAD) when performed (77067) screening digital tomosynthesis for mammography (77063) provided
on February 20, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that the medical records provided support the
necessity of the services in dispute. 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. Nonemergent
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 screening mammography, including computer-aided detection (CAD) when performed (77067) screening digital tomosynthesis for mammography (77063) provided on February 20, 2021 by an out of network (OON) provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical removal of mesh from prior hernia repair. He was treated for encephalopathy, alcohol withdrawal, pneumonia, respiratory failure and acute kidney injury. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided January 14, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that you believe you are being charged twice for the services. The Plan denied your request. The Plan says they have contacted the provider to confirm that you have only been charged a total $20 copayment for the services.

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 copayment for each Medicare covered vision exam.

You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided January 14, 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of hip, ankle and wrist fractures after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on March 17, 2021.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery. 

You have been asked to pay a $300 copayment for a diagnostic colonoscopy. The colonoscopy that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy provided by a participating provider on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and investigational.

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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar pain with radiculopathy. The provided records do not document moderate lumbar spinal or neuroforaminal stenosis at the requested service level. The documentation is insufficient to support that the other elements of the coverage rule are 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic care to treat spondylosis.

You asked the Plan to pre-approve the chiropractic care. You say that you need to get chiropractic care due to your lower back and neck pain, and other issues resulting from your scoliosis diagnosis. The Plan denied your request. The Plan says you do not meet criteria for the requested chiropractic services.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

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 chiropractic care for spondylosis. Our physician reviewer found the record indicates that you have spondylosis. Neither physical examination nor imaging demonstrates subluxation. The elements of the coverage rule are not satisfied. The requested service cannot be 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 the chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic care to treat spondylosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on March 9, 2021.
You asked the Plan to waive the copayment for office visit. You say that you were told you did not have a copayment because this was a wellness visit. The Plan denied your request. The Plan says the copayment amount 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 $15 copayment for each primary care office visit. The record shows that this visit addressed non-routine services, so a primary care office visit with applicable copayment was billed in addition to the annual wellness visit which you are not being charged for. 
You have been asked to pay $15 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 primary care office visit provided on March 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) provided February 22, 2021.

You asked the Plan to waive the copayment for the emergency visit. You say that based on your experience, you do not feel you should be responsible for these charges. You stated you were prescribed medication you were allergic too and left alone unable to breathe with no breathing treatment offered. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $120 copay for each emergency room visit for Emergency care.

You have been asked to pay $120 copay for each emergency room visit for the emergency visit. the emergency visit falls within the Emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency department visit (99282) provided February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for non-impregnated sterile gauze (A6219) provided on April 8, 
2021, by an out of network provider. 
 
You asked the Plan to pay for sterile gauze. You say that the requested items/services were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met. 
 
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 
items/services 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 non-impregnated sterile gauze (A6219) provided 
on April 8, 2021, by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services provided by a 
participating provider on November 30, 2019, to December 3, 2019. 
 
You asked the Plan to waive the copayment for observation services. You say that your husband was admitted. 
The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $300 copayment for outpatient hospital services/observation.  
 
The enrollee has been asked to pay a $300 copayment for observation services. Unless the provider has written 
an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for 
outpatient observation services, even if this results in an overnight stay. Observation services fall within the outpatient hospital services/observation benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for observation services provided by a participating provider on November 30, 2019, to December 
3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (00670) provided on September 8, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 00670 is "Anesthesia for extensive spine and spinal cord 
procedures (eg, spinal instrumentation or vascular procedures)". 
 
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 use 
of code 00670 is not supported by the records provided. Our physician reviewer found that the case file does not contain an anesthesia report. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (00670) provided on September 8, 2020.