Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99223) provided on February 7, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration
because these services were rendered by two different providers. The Plan denied your request. The Plan says
that the Global Surgical Package includes evaluation and management visits rendered the same day as a minor
surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that carriers do not include services of other
physicians except where the surgeon and the other physician(s) agree on the transfer of care in the payment
amount for a procedure with the appropriate indicator in Field 16 of the MFSDB.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the subsequent hospital care have been met. Specifically, the record does not indicate that the
surgeon has agreed on a transfer of care. The surgery and subsequent hospital care services were rendered by
separate providers. Therefore, we decided that the Plan has to pay for subsequent hospital care (99223)
provided on February 7, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve balloon dilation of the sinuses.
You asked the Plan to pre-approve the balloon dilation. You say that you would like reconsideration because
this service is medically necessary. The Plan denied your request. The Plan says the records do not show that
you meet Medicare criteria for the coverage of this service.
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 the balloon dilation. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the physician recommended balloon dilation of the sphenoid sinus based on a
computed tomography scan from 2017 (3 years prior to the time of the office visit). Also, the ENT states there
is "some mucosal thickening in the sphenoid sinuses", but this is not stated in the radiology report.
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 balloon dilation have not been met. Therefore, we decided that the Plan does
not have to pre-approve balloon dilation of the sinuses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on November 14, 2019.
You asked the Plan to pay for the hearing aids. You say that The Plan denied your request. The Plan says that there is no coverage for Hearing Aids when received from a provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered directly from this provider. We looked at the file and the Plan's rules. The file indicates the hearing aids were not ordered from them. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the sacroiliac (SI) joint injection provided on November 19, 2019.
You asked the Plan to pay for the SI joint injection. You say that the provider's credentials have been provided to show that he is eligible to provide these services. The Plan denied your request. The Plan says that the provider is no longer credentialed or eligible for Medicare/Medicaid billing of services.
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. The documentation provided in the case file does not support that the treating physician had an inactive license on the date of service in question. Review of the Registration website, the provider at issue in this case has an active medical license. No other documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the sacroiliac (SI) joint injection provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable gaseous oxygen system purchased
on September 11, 2019.
You asked the Plan to reimburse you for the portable gaseous oxygen system. You say that the Plan
representative told you that you would be reimbursed 80%. The Plan denied your request. The Plan says the
record does not show the representative told you that you would be reimbursed 80%. The Plan says the provider is not a Medicare certified supplier.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or provider who has opted out of the program except in
cases involving emergencies or urgently needed care. Medicare rules say that only rented oxygen equipment is
eligible for coverage.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Purchased oxygen equipment is statutorily noncovered
by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the portable
gaseous oxygen system purchased on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392)
provided on March 5, 2020.
You asked the Plan to pay for the dental services. You say that the procedure should be covered. The Plan
denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for resin-based composite - two
surfaces, posterior (D2392) provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of inpatient services.
You asked the Plan to pre-approve additional days of inpatient services. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
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 additional days of inpatient services.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found you were admitted to the hospital after a mechanical fall at home. You
were noted to be hypotensive and had evidence of acute kidney injury and a urinary tract infection. You were
treated with IV fluids and IV antibiotics. You are not hemodynamically stable and was tolerating her medical
regimen. The documentation does not support that you met criteria for additional inpatient days.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional days of inpatient services have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional days of inpatient services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of a breast implant, surgery for a new breast
implant and septoplasty to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve removal of a breast implant, surgery for a new breast implant and
septoplasty to be provided by an OON provider. You say that the services are necessary. The Plan denied your
request. The Plan says there are in-network providers that are able to provide these services. Therefore,
coverage criteria has not been met.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
removal of a breast implant, surgery for a new breast implant and septoplasty to be provided by an out of
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on February 18,
2020.
You asked the Plan to waive the copayment for the mammogram. You say that you weren't charged for your
last tomosynthesis. You say that there should be no charge. 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 $35
copayment for out-of-network breast cancer screenings.
You have been asked to pay a $35 copayment for the mammogram. The mammogram falls within the "Breast
cancer screening (mammograms)" benefit category. The records show that the provider is out-of-network. 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 mammogram provided on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120)
prophylaxis - adult (D1110) and drugs or medicaments dispensed in the office for home use (D9630) provided
on February 6, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges and the cost-share. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2020 EOC benefits.
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.
Review of the file show that you received periodic oral evaluation - established patient (D0120) and
prophylaxis - adult (D1110) from an out-of-network provider. Your EOC states, you may be billed more by an
out-of-network provider if the charge is greater than MAC. Furthermore, drugs or medicaments dispensed in
the office for home use (D9630) is not listed in your EOC as a covered benefit. Therefore, we decided that the
Plan does not have to pay for periodic oral evaluation - established patient (D0120) prophylaxis - adult (D1110)
and drugs or medicaments dispensed in the office for home use (D9630) provided on February 6, 2020 by an
out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on December 19, 2019 by
an out of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that this should be covered because the hospital
was authorized. The Plan denied your request. The Plan says this service was 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 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 office visit (99212) provided on December 19,
2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from January 17, 2020
through February 15, 2020.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your
request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 pay for SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
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 care have not been met. Therefore, we decided that the Plan does not have
to pay for SNF care provided to the enrollee from January 17, 2020 through February 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from January 6, 2020 through
January 10, 2020.
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says the stay 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 pay for inpatient mental health care. Our physician
reviewer found this enrollee did not appear to require inpatient mental health treatment as she was not a danger
to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that
active treatment was taking place. It did not appear that the services were reasonably expected to improve the
patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment
found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon
review the records provided for the admission of this patient does not meet criteria for acute inpatient mental
health treatment as she was not shown to be a danger to herself or others, visual hallucinations, however this
patient did have auditory hallucination. She is noted to be cooperative and compliant with treatment while not
showing any aggressive behaviors.
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 mental health care have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient mental health care from January 6, 2020 through January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 2,
2018 through November 12, 2018 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2018 EOC 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).
Review of the file show that you received inpatient hospital care from November 2, 2018 through November
12, 2018 provided by an in-network provider. The plan should have applied a $395 copayment for four (4) days
of inpatient hospital, instead of three (3) days. The claim had been manually processed and it was processor
error that only 3 days of copayments were applied to the claim. Since this was the plan's error, they will not
adjust the copayment from 3 days of inpatient hospital care copayments to 4 days. Your EOC states, enrollees
must pay a $395 copayment each day for days 1 to 4 for in-network Medicare-covered hospital care. 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 inpatient hospital care from November 2, 2018 through
November 12, 2018 provided by an in-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retroperitoneal ultrasound.
You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet the criterion for additional imaging at this time.
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 the ultrasound. Our reviewer says that
the requested ultrasound is not considered medically reasonable and necessary in this case. Our physician
reviewer found it is noted at the time of patient encounters on December 19, 2019, and by phone on May 4,
2020, that the enrollee has no symptoms related to the AAA, and that the enrollee is hemodynamically stable.
The enrollee's other medical problems include tobacco abuse, hypertensive heart disease, chronic kidney
disease, stage 3, elevated glycosylated hemoglobin, and tobacco abuse.
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 ultrasound have not been met. Therefore, we decided that the Plan does not
have to pre-approve retroperitoneal ultrasound.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on January 31, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says documentation submitted did not indicate the provider
discussed the need for the billed supply code, therefore the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The medical record does not mention or support medical necessity
for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral
orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbarsacral
orthosis provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out
of network (OON) provider.
You asked the Plan to pre-approve a second opinion consultation. You say that your primary care physician
suggested you get a second opinion. The Plan denied your request. The Plan says there are in-network
providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a second opinion consultation to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical alert system.
You asked the Plan to pre-approve medical alert system. You say that the service is medically necessary. The
Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve medical alert system.