Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on October 6, 2019 by an out-of-network provider.You asked the Plan to pay forthe services. You say that the member was not able to choose which physician(s) treated him during this inpatient admission.The Plan denied your request. The Plan says the member self-directed for out-of-network care.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 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 forthe services provided to the enrollee on October 6, 2019 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an MRI and arthrocentesis provided on January 7, 2020 and January 28, 2020.You asked the Plan to waive the copayments for an MRI and arthrocentesis. You say that you disagree with the charges.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 $275 copayment for each advanced imaging service and a $250 copayment for each outpatient surgery services.You received an MRI on January 7, 2020. Therefore, you are responsible to pay the allowed amount of $197.19, which is less than the $275 copayment.  You received arthrocentesis on January 28, 2020. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $221.51, which is less than the $250 copayment. The total amount you owe is: $418.70. You have been asked to pay the total copayment amount of $418.70 for an MRI and arthrocentesis. An MRI and arthrocentesis fall within the outpatient hospital 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 for an MRI and arthrocentesis provided on January 7, 2020 and January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve midazolam hydrochloride, alteplast recombinant, and Fentanyl citrate for tunnel cathedral procedure.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 services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted documentation does not include medication orders, dose, route, or medication administration records. Without the support of documentation, medical necessity of the requested drugs for the non-functioning catheter exchange procedure is not supported.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 midazolam hydrochloride, alteplast recombinant, and Fentanyl citrate for tunnel cathedral procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 31, 2019.You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the provider did nothing.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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on March 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99214 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 and POS codes.In this case, the CPT Code Manual definition of code 99214 is established patient office or other outpatient, visit typically 25 minutes.We find that CPT code 99214 is not supported in the medical record. Specifically, this code is for an office visit and the file shows that the claim was billed with a POS code of 23 for an emergency room. This POS code does not match the CPT code definition. 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 forthe services rendered on March 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on November 20, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that there were no services performed during your emergency room visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. The medical record shows you were examined and evaluated during your emergency room 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 emergency room visit provided on November 20, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scans provided on June 20, 2019.
You asked the Plan to waive the copayment for the CT scans. You say that you were charged two copayments for the same scan on the same day. You say that there should only be one copayment. 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 $225 for each in-network, Medicare-covered diagnostic radiology service. You have been asked to pay a $225 copayment for each CT scan.
Service
Allowed Amount
Standard Copayment
Member Liability
CT Scan of Thorax
$450.82
$225
$225
CT Scan of Abdomen/Pelvis
$981.96
$225
$225
TOTAL:
$500
The CT scans 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. The records show that two scans were performed. 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 CT scans provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you went to get your prescription signed. You say that you did not know it would be considered an office visit. The Plan denied your request. The Plan says no prior authorization was 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 services that were provide fall under an office visit. 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 an office visit provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveImfinzi (J9173).
You asked the Plan to pre-approveImfinzi. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not supported for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Imfinzi. Our reviewer says that Imfinzi is medically reasonable and necessaryin this case. Our physician reviewer found Imfinizi is FDA approved for the treatment of unresectable stage III non-small cell lung cancer in adults whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy. Although this patient has a recurrence, it is local and being treated as a stage III lung cancer. The service is reasonable and 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 Imfinzi have been met.Therefore, we decided that the Plan has to pre-approveImfinzi (J9173)
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you are not in a condition to leave the facility. The Plan denied your request. The Plan says that you have exhausted your 100-day limit for SNF services during your benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. We looked at the file and Medicare rules. The records show that you were discharged from inpatient care on November 2, 2019. Your next admission shows to be January 28, 2020. More than 60 days had gone by in a row without inpatient hospital or SNF care. Based on this information, we decided that Medicare rules for coverage have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
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 the medical services provided to the enrollee by an out-of-network provider on October 28, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on December 16, 2019.
You asked the Plan to pay for the dental services. You say that you paid for the services that you received on October 29, 2019. You say that you feel you have not overused your benefit. You also say that you should not have been billed for the services you received on December 16, 2019. The Plan denied your request. The Plan says 1 oral exam is covered every 6 months. The Plan says 1 set of bitewings is covered every 6 months. The Plan also says the frequency limit for these services 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 and oral exams and bitewing x-rays are covered services, the frequency limits have been exceeded. The record shows that the Plan paid for the oral exam and bitewing x-rays that you received on October 29, 2019. The record also shows that the payment you made for the services on October 29, 2019 were applied to the topical application of fluoride, as it is not a covered service, and a $10 deductible was applied to the oral exam. The Evidence of Coverage clearly states there is $10 deductible for preventive dental services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on December 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional physical therapy visits.
You asked the Plan to pre-approve ten additional physical therapy visits. You say that the enrollee needs these services. The Plan denied your request. The Plan says improvement is not likely so continued physical therapy is not necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional physical therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has had 14 prior therapy visits and the documentation reveals continued falls as patient having carryover difficulty and not using safety skills from therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed an approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 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 for physician services provided on November 21, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission.
You asked the Plan to pre-approve inpatient hospital admission. You say that the enrollee should remain in the hospital a few more days for observation to make sure she remains stable. 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. 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 inpatient hospital admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee had been clinically stable since April 11, 2020 and was recommended to return home with Home Health services. Additionally, the enrollee did not require IV medications or any further imaging or testing/procedures. The Plan's review determined the enrollee did not have any acute care needs; therefore, she was stable for discharge on April 11, 2020 and remained stable for discharge from the hospital since that date. Throughout the enrollee's stay on observation status she did not meet the clinical criteria for acute hospital admission. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx pen injection 300 dose for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the enrollee has no pharmacy benefit.
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 Cosentyx pen injection 300 dose for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740), post and core in addition to a crown (D2954), and endodontic therapy (D3330).
You asked the Plan to pre-approve the dental services. You say that you would like to save the tooth to eat with. The Plan denied your request. The Plan says that the requested dental services are not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the requested dental services are medically necessary. Our physician reviewer found tooth # 14 is in need of a root canal due to a large carious lesion and fracture extending to the pulpal area. The reviewer also found that the bone support is good and the tooth is in functional occlusion. Therefore, the requested dental services are medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740), post and core in addition to a crown (D2954), and endodontic therapy (D3330).