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

We decided that the Plan does not have to pay for the complete intraoral x-ray series (D0210), crown (D2740), core buildup (D2950) and unspecified preventative procedure (D1999) provided on January 12, 2021.
You asked the Plan to pay for the dental services. You say that you feel there has been a mistake and your current insurance plan was not billed properly. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 complete intraoral x-ray series (D0210), crown (D2740), core buildup (D2950) and unspecified preventative procedure (D1999) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the anesthesia for procedures on the eye; lens surgery (00142) provided on March 5, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 50% coinsurance for out of network surgery services provided at an ambulatory surgical center.
You have been asked to pay $57.50 (Plan allowed amount of $115.01 x 50% coinsurance) for the out of network anesthesia service provided at an ambulatory surgical center. 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 anesthesia for procedures on the eye; lens surgery (00142) provided on March 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 occupational therapy (OT) visits.
You asked the Plan to pre-approve 8 OT visits. You say that the OT is medically necessary. The Plan denied your request. The Plan says the documentation shows that your medical condition is stable, and you have completed OT in your home.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. In order to require Home health care skilled services, the enrollee must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician. Additionally, the enrollee must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound means leaving home is a major effort.
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 8 OT visits. Our reviewer says that criteria for occupational therapy services are not met. Our physician reviewer found that the documentation does not support that you require additional skilled nursing services or additional skilled rehab services to provide treatment that is medically necessary. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The Plan has approved 4 skilled nursing visits to continue monitoring a healing issue and this should be sufficient. The requested home health services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a endoscopic catheterization of the biliary ductal system (74328) and an unlisted pancreas procedure (48999) provided August 26, 2020.
You asked the Plan to pay for the catheterization and unlisted pancreas procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 74328, & 48999 is not supported in the medical record. Specifically, the report documents a stent placement, there is a more appropriate code for this procedure. The procedural report does not include documentation to support an unlisted procedure. Based on this information, we decided that Medicare rules for coverage of the catheterization and unlisted pancreas procedure have not been met.
Therefore, we decided that the Plan does not have to pay for a endoscopic catheterization of the biliary ductal system (74328) and an unlisted pancreas procedure (48999) provided August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional resin-based composite provided on February 4, 2021.

You asked the Plan to pay for the additional resin-based composite. You say that you would like to be reimbursed for this filling. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, restorations are limited to two procedure codes per calendar year. The record shows that you received five resin-based composites between January 26, 2021, and February 4, 2021, four of which were covered at the in-network rate of 50% by the Plan, and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional resin-based composite provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 26, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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 there is no evidence that the enrollee requires services that are not available in the current care setting. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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: 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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate level of 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray provided by an out-of-network provide on January 4, 2020.
You asked the Plan to pay for the x-ray. You say that you were not informed the doctor did not accept your insurance. You say that you cannot afford to make these payments. The Plan denied your request. The Plan says services provided by an out-of-network provider are not covered.
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 x-ray provided by an out-of-network provide on January 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (93306) provided on February 11, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you were informed that your cost share would be $30, and you paid this upfront at the time of service. Diagnostic tests and procedures have a $30 copayment, but you were charged $110. 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 $110 copayment for Medicare covered radiological diagnostic services. You have been asked to pay $80 ($110 - $30 payment = $80 balance) for the diagnostic service. The
diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for transthoracic echocardiography (93306) provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on January 7, 2021.
You asked the Plan to pay for the dental service. You say that this was an emergency procedure. You say that you had an abscess. You also say that you were told that some of this would be covered. The Plan denied your request. The Plan says the frequency limit has been exceeded. The Plan says that the provider in this case is out of network. The Plan also says that dental service performed out of network are not 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 extraction is not among those covered under this benefit. The record shows you only had preventive dental coverage. Extractions are not a preventive service. Therefore, we decided that the Plan does not have to pay for the extraction provided on January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after surgery.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested care is a medical necessity for the enrollee. The Plan denied your request. The Plan says none of the requirements for an inpatient hospital stay have been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found that the enrollee is to undergo a procedure that is not on the inpatient-only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities that necessitate a prolonged (i.e. two midnight) stay. The enrollee should present for, undergo, and be monitored following the procedure as an outpatient. Should complications arise which necessitate a prolonged (i.e. two midnight stay), the enrollee may then be converted to inpatient status under the two midnight rule.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bathroom safety items and wheelchair valet seat provided on December 1, 2020, through December 18, 2020.
You asked the Plan to pay for the bathroom safety items and wheelchair valet seat. You say that you would like reconsideration because this equipment is medically necessary due to your mobility issues. The Plan denied your request. The Plan says Medicare does not cover home or vehicle modifications.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the bathroom safety items and wheelchair valet seat provided on December 1, 2020, through December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the methylprednisolone injected on December 22, 2020 billed with two units of J1030.
You asked the Plan to pay for the methylprednisolone. You say that the record clearly shows that 40mg of methylprednisolone was injected. The Plan denied your request. The Plan says the record does not support two units of code J1030.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code J1030 are not supported in the medical record. The medical record shows that 40mg of this drug were injected. Each unit of J1030 represents 40mg. As such, only one unit of this code is supported. Based on this information, we decided that Medicare rules for coverage of the methylprednisolone
have not been met. Therefore, we decided that the Plan does not have to pay for the methylprednisolone injected on December 22, 2020 billed with two units of J1030.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on March 15, 2021, to March 16, 2021.

You asked the Plan to waive the copayment for an emergency room visit. You say that you did not like the care that you received. You say that you should not have to pay 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 $90 copayment for emergency care.

You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was provided, the correct copayment has been applied. An emergency room 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 an emergency room visit provided by a participating provider on March 15, 2021, to March 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvis x-ray provided on June 17, 2020.

You asked the Plan to pay for the pelvis x-ray. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the pelvis x-ray provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a sacroiliac (SI) joint injection provided on January 7, 2021 by an out of network (OON) provider.
You asked the Plan to pay for SI joint injection. You say that you are requesting the Plan to approve authorization for this claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 a sacroiliac (SI) joint injection provided on January 7, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom MyPro Motion G orthosis (L8702).
You asked the Plan to pre-approve a custom MyPro Motion G orthosis. You say that evidence supports that this is an effective treatment. The Plan denied your request. The Plan says this is experimental.
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 a custom MyPro Motion G orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found based on scientific evidence, professional standards, and expert opinion, the MyoPro is not known to be effective in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. 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 custom MyPro Motion G orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom MyPro Motion G orthosis (L8702).