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

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 21, 2021
You asked the Plan to pay for the periodontal maintenance and topical application of fluoride. You say that you are covered for 2 fluoride treatments per calendar year. The Plan denied your request. The Plan says this service is not a covered benefit under your plan guidelines.
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 periodontal maintenance provided on January 21, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (CPT 99053) provided to the enrollee on October 26, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says payment for covered services are always bundled into payment for other services not specified.

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 99053 is "Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.

We asked our coding 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 services at issue in this case were not supported by the medical records. Our physician reviewer found per CMS "This policy addresses reimbursement of after hours and weekend care services (Current Procedural Terminology (CPT) codes 99050-99060). The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified.These codes have a Status Indicator of "B" in the National Physician Fee Schedule (NPFS). Consistent with CMS, Medicare considers these codes not eligible for reimbursement. Indicator B - Bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient). Therefore, this is not a covered service.

We looked at this coder'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 emergency room services (CPT 99053) provided to the enrollee on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 21, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were not seen this day because you were refused a visit. You say that you will not pay for services that were not rendered. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for in-network specialist visits. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you received services with a specialist during the 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 office visit provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a PCP visit. We decided that the Plan does not have to reduce the cost-sharing charges for a PCP visit to the amount you requested.

You asked the Plan to waive the copayment for a PCP visit. You say that this was a preventative visit and you disagree with the charges. The Plan says that the claims were processed correctly and you are being charged the correct amount.

We decided that the Plan has to reduce the cost-sharing charges for a PCP visit from $30 to $10.

The medical records show that you had a telehealth visit with your PCP. Therefore, you cannot be asked to pay more than a $10 copayment for the visit.

The Plan contract says that you cannot be asked to pay more than a $10 copayment for PCP telehealth visits. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a PCP visit from $30 to $10.

We also decided that the Plan does not have to waive the $10 copayment for a PCP visit.

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 $10 copayment for a PCP visit. The medical records provided show that you received services beyond an annual wellness visit. Therefore, we decided that the Plan does not have to waive the $10 copayment for a PCP visit.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for procedures on the head (00104) provided October 15, 2020 to October 21, 2020.

You asked the Plan to pay for the anesthesia services. You say that you have billed correctly. The enrollee is receiving outpatient recurrent services. Your medical anesthesia services were requested by the surgeon based off medical necessity.The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service 22(outpatient).

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, we find that CPT code 00104 is not supported in the medical record. Specifically, the claim was billed with an inappropriate place of service. According to claims history, the enrollee was inpatient during this date of service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on the head (00104) provided October 15, 2020 to October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skin biopsy provided on September 9, 2020.

You asked the Plan to waive the copayment for a skin biopsy. You say that you disagree with the charges because you feel that you should only owe a $20 copayment.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 $240 copayment for outpatient surgery,including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a skin biopsy at an ambulatory surgical center on September 9, 2020. A skin biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $240 copayment. 

You have been asked to pay a $240 copayment for a skin biopsy. A skin biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 skin biopsy provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient services (99214) provided on November 4, 2020.

You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the documentation submitted does not support the place of service code billed.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded the initial claim to verify the place of service code that was billed. It is the burden of the Health Plan to substantiate their denial with evidence. The denial is not substantiated so we must find in your favor.Therefore, we decided that the Plan has to pay for the outpatient services (99214) provided on November 4, 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 waive the copayment for the hearing aid check (92593) provided on December10, 2020.

You asked the Plan to waive the copayment for the hearing aid check. You say that this service was not related to hearing aids, but to previous problems you had with your ear canal and irrigation. The provider was checking to see if the hearing aid may have caused another issue. You do not think the Plan's required hearing provider could have provided these services.The Plan denied your request. The Plan says hearing tests and hearing aid tests require a $15 copayment when they are not provided by the Plan's hearing provider. Medical records were provided to support that this service was completed as billed.

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 routine or diagnostic hearing aid exams provided by someone other than the Plan's listed provider. You have been asked to pay a $15 copayment for the hearing aid check. A hearing aid check can fall into the annual routine hearing test benefit category, or possibly the diagnostic hearing exam category depending on why the service is needed. Both categories require a $15 copayment when services are not provided by the Plan's specified hearing provider. 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 hearing aid check (92593) provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on September 22, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you think this should be covered 100%. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $728. The total amount you are being asked to pay is $145.60 ($728 x 20% = $145.60). An injection falls within the Medicare Part B prescription 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 an injection provided by a participating provider on September 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of an implant provided on December 1, 2020.
You asked the Plan to waive the copayment for the removal of an implant. You say that you were told that you would not owe a copayment for the second surgery. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received the removal of an implant at an outpatient hospital facility on December 1, 2020. The removal of an implant is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for the removal of an implant. The removal of an implant falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 removal of an implant provided on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from April 15, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient psychiatric care from April 15, 2021 and forward. You say that the continuation of inpatient psychiatric care from April 15, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient psychiatric care from April 15, 2021 and forward is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 continuation of inpatient psychiatric care from April 15, 2021 and forward. Our reviewer says that the continuation of inpatient psychiatric care from April 15, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee does not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician.

Based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health setting beyond the date in question of April 15, 2021 and forward and the enrollee can be treated in a lesser restrictive setting as he is not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression and was being cooperative and compliant while not showing any acute threats to safety.

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 continuation of inpatient psychiatric care from April 15, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care from April 15, 2021 and forward.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the urgent care visit provided by an out-of-network provider on March 16, 2020.
You asked the Plan to pay for the urgent care visit. You say that you attached medical notes for the claim. You say that the claim should be paid at a level 4. The Plan denied your request. The Plan says that the provider is not in-network.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 urgent care visit. Our reviewer says that the records indicate the care provided at the urgent care visit was medically necessary. Our physician reviewer found the enrollee's blood pressure was 180/80 and the enrollee was diagnosed with viral bronchitis. Our reviewer says that it would not have been medically reasonable to delay the services until the enrollee returned to their service area. 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 urgent care visit have been met. Therefore, we decided that the Plan has to pay for the urgent care visit provided by an out-of-network provider on March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary.

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 these services. Our reviewer says that the inpatient level of care is not medically necessary. Our physician reviewer found the enrollee requires a total knee arthroplasty. The records do not indicate that she has uncontrolled or unstable medical conditions necessitating a prospective inpatient admission. for the planned surgery. The records do not support a reasonable expectation that the enrollee will require a length of stay spanning 2 or more midnights. The inpatient admission is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays and four 2D oral/facial photographic images provided on December 14, 2020.
You asked the Plan to pay for the additional intraoral periapical x-rays and 2D oral/facial photographic images. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services 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 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 two additional intraoral periapical x-rays and four 2D oral/facial photographic images provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 11, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were informed everything would be covered. The Plan denied your request. The Plan says the $45 specialist copayment applied correctly and the $250 copayment for each MRI will be waived as a one-time exception.
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 $45 copayment for in-network physician specialist services. You have been asked to pay a $45 copayment. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was with a specialist. 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 office visit provided on November 11, 2020.