Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient mental health services provided
September 24, 2019 to March 25, 2020 from an out of network provider.
You asked the Plan to waive the coinsurance for the outpatient mental health services. You say that during your
preliminary meeting the doctor informed you that she was a certified in network provider for Medicare, that
your appointments would be totally covered and you had unlimited number of visits. The Plan denied your
request. The Plan says the plan has reprocessed claims January 29, 2020 through March 25, 2020 as innetwork.
The claims have been processed correctly per the plan benefits.
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 40%
coinsurance for out of network outpatient mental health services per the 2019 EOC and 50% coinsurance for
out of network outpatient mental health services and $40 for in network outpatient mental health services for
Outpatient mental health care per the 2020 EOC.
You have been asked to pay $1,041.04 for the outpatient mental health services. The outpatient mental health
services fall within the Outpatient mental health 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
coinsurance for outpatient mental health services provided September 24, 2019 to March 25, 2020 from an out
of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forPT provided from June 24, 2020, to July 23, 2020.You asked the Plan to waive the copayments forPT. You say that you state that the hospital can charge whatever they want so you stopped seeing the provider.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct amount.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 $40 copayment for outpatient rehabilitation services provided in an outpatient hospital facility.You received PT at an outpatient hospital facility from June 24, 2020, to July 23, 2020 for a total of 4 visits. Therefore, you are responsible to pay a $40 copayment per eachvisit. The total amount you owe is: $40 (copayment) x 4 (PT visits) = $160.  You have been asked to pay the total copayment amount of $160 for PT. PT falls within the outpatient rehabilitation services 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 forPT provided from June 24, 2020, to July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge day management services provided on April 7, 2020 billed with code 99239.
You asked the Plan to pay for the discharge services as billed. You say that these codes should be paid. The Plan denied your request. The Plan says it was decided to make payment for all codes aside from 99239, as there is no documentation submitted to support this code.
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 99239 is Hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, no progress note was submitted to show that more than 30 minutes was spent with the patient providing this service. Based on this information, we decided that Medicare rules for coverage of the discharge services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the discharge day management services provided on April 7, 2020 billed with code 99239.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on May 25, 2020 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring facility is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 has network providers available who can provide 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 forskilled nursing services provided on May 25, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care and surgical procedure provided February 10, 2020, to April 9, 2020.
You asked the Plan to waive the copayment for the medical services. You say that you do not understand why you are receiving this bill because you already reached your out-of-pocket maximum. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 $295 copayment each day for days 1-5 for inpatient hospital care, $0 copayment for additional days. for inpatient hospital care. You have been asked to pay a total cost share of $1475 for your inpatient care provided from February 10, 2020, to February 18, 2020 and a $5 copayment for the surgical procedure you received April 9, 2020. The April 9, 2020 surgical procedure met your out-of-pocket maximum, so you are only being charged $5. The inpatient hospital care was provided before you met your out-of-pocket maximum and you are still responsible for the payment. 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 inpatient hospital care and surgical procedure provided February 10, 2020, to April 9, 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 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require physician evaluation. Your care needs can be met at a lower level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 14, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is
important to know which providers are part of our network because, with limited exceptions, the enrollee must
use network providers to medical care and services. The only exceptions are emergencies, urgently needed
services when the Plan's network is not available, out-of-area dialysis services, and cases in which the Plan
authorizes use of out of network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. 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 physician's services provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150) and sales tax (D9985) provided.

You asked the Plan to pay the in network rate for the dental service. You say that after you had a questionable visit with the provider in this case, you called the Plan to ask about getting a second opinion. You say that you assumed that as long as the dentist accepted your plan coverage, you would be okay. You say that you did not realize you needed to check to see if the dentist was okay. You say that the plan representative never used "in network or out of network," nor offered to send a list of in network dentists. You also say that the services should be covered at the in network rate.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that when you receive services out of network you are responsible for the difference between the dentist's billed amount and the fee schedule amount. The Plan also says that sales tax is not a covered service.

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, you are responsible for the difference between what the provider bills and what the Plan pays when you receive services out of network. The record shows that in your phone call to the plan, you did not inquire about the network status of the provider in this case. Additionally, sales tax is not among those covered under this benefit.Therefore, we decided that the Plan 
does not have to pay the in network rate for the comprehensive oral evaluation (D0150) and sales tax (D9985) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make payment for the replacement Request for Anticipated Payment
(RAP) for home health services for episode of care beginning February 1, 2020.
You asked the Plan to make payment for the replacement RAP. You say that this was originally filed with TOB
0322 and was denied due to missing value codes. A new RAP was submitted with TOB 0327 per regulations
which should be paid. The Plan denied your request. The Plan says this was submitted on an incorrect TOB.
The Plan must follow Medicare rules. Medicare rules say that TOB 0322 is used for an original or replacement
RAP and 0328 is used to void a previously submitted RAP.
In this case, a replacement RAP would have been correctly filed with a TOB 0322 along with a TOB 0328,
voiding the original. Use of TOB 0327 is for replacement claims only, not for replacement RAPs. Therefore,
we decided that the Plan does not have to make payment for the replacement Request for Anticipated Payment
(RAP) for home health services for episode of care beginning February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on August 20, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that this visit should be covered under preventative services.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 $30 copayment for physician specialist services. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the physician specialist services 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 forthe specialist office visit provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable


We decided that the Planhasto pre-approvea right percutaneous SI joint fusion for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say services are covered when they are medically necessary and meet the relevant Medicare criteria.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 surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the proposed procedure is medically reasonable and necessary.  She meetsall of the criteria of the LCD. The enrollee had positive SI joint pain, and three positive provocative exam tests. The enrollee had diagnostic joint injections which gave 80 pain relief. The imaging supports the enrollee's diagnosis.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 surgery have been met.Therefore, we decided that the Planhas to pre-approvea right percutaneous SI joint fusion for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe lab services you received from an outpatient hospital facility on August 18, 2020.You asked the Plan to waive the copayment forthe lab services. You say that you were not aware that yournew doctor used an outpatient hospital facility for lab services.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 $50 copayment for lab services at an outpatient hospital facility. You have been asked to pay a $50 copayment for the lab services. 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 forthe lab services you received from an outpatient hospital facility on August 18, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on February 22, 2020 through March 22, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the documentation indicates the services are not necessary for the treatment of the member's condition.
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 neuromuscular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no clinical notes from the member's primary health provider. 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 neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on February 22, 2020 through March 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the right hip for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the material submitted for review consists of notes concerning the evaluation for the requested MRI by representatives of the plan. Those notes describe an injury with twisting of the ankle on 10/23/20. The submitted materials indicate a steroid injection into the right hip has occurred. However, the submitted materials do not include medical records including x-ray findings of the right hip or even a physical exam. Unless there is a documented suspicion of fracture despite a negative xray, suspicion of infection, or of avascular necrosis a 6 week trial of PT is indicated prior to approving MRI. Unfortunately, the submitted materials do not provide such information such that at this point medical necessity for the requested MRI of the right hip has not been established by the materials submitted for this review. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the right hip for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vraylar 1.5mg capsules.
You asked the Plan to pre-approve the Vraylar capsules. You say that the requested medication is necessary for
the enrollee's condition. The Plan denied your request. The Plan says this is an oral drug that cannot be covered
by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
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 pre-approve Vraylar 1.5mg capsules.
Benefits for the Vraylar capsules may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant removal provided on July 2, 2020.

You asked the Plan to pay for the implant removal. You say that you feel the Plan only paid a very small
amount, since you had used none of the $2,000 that you are entitled to for the year. The Plan denied your
request. The Plan says this service is not a covered benefit because it is related to dental implants.

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
implant removal provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophageal laryngoscopy you had on
July 15, 2020 at an ambulatory surgical center.
You asked the Plan to waive the copayment for the esophageal laryngoscopy. You say that you believe that this
procedure is a diagnostic test, not a surgery service, so your copayment should only be $25. 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 $275
copayment for outpatient surgery at an ambulatory surgical center.
You have been asked to pay a $275 copayment for the esophageal laryngoscopy. Esophageal laryngoscopies
are considered surgical services by Medicare, so this service falls within the outpatient surgery at an
ambulatory surgical center 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
esophageal laryngoscopy you had on July 15, 2020 at an ambulatory surgical center.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three additional intraoral periapical x-rays provided on
July 29, 2020.
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you feel you should not
pay for services you did not request. 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, intraoral x-rays and are limited to one
procedure per calendar year. The record shows that you received multiple additional intraoral x-rays on July
29, 2020, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the three additional intraoral periapical x-rays provided on July 29, 2020.