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

We decided that the Plan does not have to pay for the core build up (D2950), crown (D2740), root canal (D3330), and root canal (D3320) provided on April 27, 2021.
You asked the Plan to pay for the dental service. You say that you verified with the plan that the provider in this case was in network and the services would be covered. The Plan denied your request. The Plan says the provider in this case is excluded from receiving payment for services performed according to the United States Office of the Inspector General.
The Plan must follow Medicare rules. Medicare rules say that Medicare has the authority to exclude various health care providers from receiving payment under Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met. Specifically, the record shows that these services were provided by a provider that is excluded from the Medicare program. Therefore, we decided that the Plan does
not have to pay for the core build up (D2950), crown (D2740), root canal (D3330), and root canal (D3320) provided on April 27, 2021.
Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your rehabilitation needs can safely be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care center visit you had on February 12, 2021.

You asked the Plan to waive the copayment for the urgent care center visit. You say that you thought you only had a $20 copayment and there is nothing on your card about urgent care. 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 $55 copayment for urgent care visits. 

You have been asked to pay a $55 copayment for the urgent care center visit. 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 urgent care center visit you had on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular testing provided on October 13, 2020.

You asked the Plan to pay for the comprehensive cardiovascular testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says genetic testing for cardiovascular risk factors has negligible benefit in the management of a member's health.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the comprehensive cardiovascular testing have not been met. Specifically, there is insufficient information to determine if Medicare coverage criteria have been met. The documentation submitted does not include any clinical information to verify why this testing was ordered and how it will be used to treat the member's condition. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular testing provided on October 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received from March 4, 2021, to March 24, 2021.

You asked the Plan to waive the copayments for the PT services. You say that you already paid $30, so this balance is not correct. The Plan denied your request. The Plan says you were charged these copayments 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 physical therapy visit. 

Records show that you had four PT visits between March 4, 2021, and March 24, 2021. You have been asked to pay a $15 copayment for the PT 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. If you have questions about your outstanding balance if you have paid towards these copayments, please contact the provider of service directly. Therefore, we decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received from March 4, 2021, to March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chiropractic manipulative treatment (98940) and the office visit (99202) provided from April 23, 2021, through June 11, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $20 copayment per visit for chiropractic services. 

You have been asked to pay $140 ($20 copayment x 7 visits) for the chiropractic services provided. 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 chiropractic manipulative treatment (98940) and the office visit (99202) provided from April 23, 2021, through June 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a preventive medicine evaluation visit provided on March 10, 2020.

You asked the Plan to waive the copayment for preventive visit. You say that this was a preventive visit that should be covered by the Plan at 100%. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay $0 copayment for annual preventive visit. Although the provider did not bill with the standard Annual Wellness Visit code, the provider did bill this visit as a preventive visit and the Plan chose to cover this claim as such. Therefore, no cost-sharing applies to this claim. 

The Plan says you must pay $25 copayment for preventive visit. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for preventive visit. Therefore, we decided that the Plan has to waive the copayment for a preventive medicine evaluation visit provided on March 10, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) provided April 19, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you changed to a different dentist
and were not aware there were different exam types. The Plan denied your request. The Plan says you have
exceeded frequency limits for this 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, 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
comprehensive oral evaluation - new or established patient (D0150) provided April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on January 22, 2021.

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 procedure code 99223 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 99223 is Level 3 initial hospital care for evaluation and management of patient with problem of high severity, including comprehensive history and physical examination, and medical decision-making of high complexity, typical time 70 minutes. 

We find that CPT code 99223 is not supported in the medical record. Specifically, there is no documentation of 70 minutes of Level 3 initial hospital care spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on January 22, 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's ongoing skilled therapy and nursing needs can be provided 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 weakness, hypotension and urinary tract infection. The enrollee's medical problems 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided in an outpatient setting from May 25, 2021, to May 27, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital for surgery. You say that you brought your medication with you. You say that you were not allowed to take medication unless they administered it. You also say that these should be covered. The Plan denied your request. The Plan says the drug that you received are considered self-administered. The Plan says self-administered drug are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs that you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for 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 pay for the self-administered drugs (A9270) provided in an outpatient setting from May 25, 2021, to May 27, 2021.

Benefits for the self-administered drugs 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: 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 your 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 you are a 60-year-old woman with a medical history notable for heart disease, diabetes, hypertension, chronic kidney disease, was admitted to the acute care hospital on August 7, 2021. The enrollee was diagnosed with Coronavirus, hypotension, a syncopal episode, acute kidney injury on chronic kidney disease, and an elevated troponin. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. You are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected in this case. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 11, 2020,
by an OON provider.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit.

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 lumbar-sacral orthosis provided on November
11, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on February 16, 2021.

You asked the Plan to pay for a crown, and a core buildup. You say that you told your provider that the Plan would only cover one crown. The Plan denied your request. The Plan says the crown is a covered benefit, but you have exceeded the frequency limit of one per year. The core buildup is not a covered 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown, and a core buildup have not been met. Specifically, the record shows that you had exceeded the frequency limit for crowns. Additionally, a core buildup is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on February 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided from March 19, 2021 to April 12, 2021.
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that this is an approved code. The Plan denied your request. The Plan says payment for this code is bundled into payment for other services.
The Plan must follow Medicare rules. Medicare rules say that status indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99072 has a status indicator of B, meaning payment is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of
additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) provided from March 19, 2021 to April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (49568) provided on December 23, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an add-on 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.

We find that CPT code 49568 is not supported in the medical record. Specifically, this is an add-on code. Add-on
codes must be reported with an appropriate primary procedure code. The add-on code in this case was not
reported with an appropriate primary procedure code. 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 (49568) provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided by a participating provider on June 7, 2021.
You asked the Plan to waive the copayment for urgent care services. You say that you do not feel like your visit warrants this level of copayment. 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 $60 copayment for urgently needed services.
You have been asked to pay a $60 copayment for urgent care services. Since an urgent care visit did occur, the correct copayment has been applied. Urgent care services fall within the urgently needed 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 for urgent care services provided by a participating provider on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Hymovis injections you received on April 8, 2021.
You asked the Plan to waive the coinsurance for the Hymovis injections. You say that you were never told that you would be responsible for anything other than a $35 copayment. You say that you cannot afford this amount. 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 Hymovis injections. The Hymovis injections fall 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 Hymovis injections you received on April 8, 2021.