Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an insulin pump, battery and supplies (A4230, K0455, K0605).
You asked the Plan to pre-approve the insulin pump, battery and supplies. You say that the pump is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that insulin pumps are covered when medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insulin pump, battery and supplies. Our reviewer says that the requested insulin pump is not medically necessary. Our physician reviewer found the records provided were insufficient to show that the new insulin pump was 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 the insulin pump, battery and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve an insulin pump, battery and supplies (A4230, K0455, K0605).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuing inpatient behavioral health stay from July 28, 2021 forward.
You asked the Plan to pre-approve an inpatient behavioral health stay from July 28, 2021 forward. You say that the enrollee is still exhibiting behaviors and requires a continued inpatient behavioral health stay. The Plan denied your request. The Plan says inpatient psychiatric hospitalization is not medically necessary after July 27, 2021.
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 an inpatient behavioral health stay from July 28, 2021 forward. Our reviewer says that the continuing inpatient psychiatric stay is not medically necessary starting July 28, 2021. Our physician reviewer found that the health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did 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 auditory or visual hallucinations or behavioral issues. 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 patient's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 28, 2021 and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient behavioral health stay from July 28, 2021 forward have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuing inpatient behavioral health stay from July 28, 2021 forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient home services (99350) provided on
March 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that please find attached below required documents and
issue payment for the denied claim as your provider performed the services in good faith. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
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 established patient home services (99350)
provided on March 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367), caries
risk assessment and documentation (D0602), and comprehensive oral evaluation (D0150) provided on April 29,
2021.
You asked the Plan to pay for the cone beam CT capture and interpretation, caries risk assessment and
documentation, and comprehensive oral evaluation. You say that you tried to get urgent treatment for an
extraction and were told you would not be able to be seen for a month. You also say that the Plan's customer
service sent you to this provider who did not do an extraction, but subjected you to do more x-rays. The Plan
denied your request.
The Plan says the cone beam CT capture and interpretation and caries risk assessment and documentation are
not covered under your benefit plan. The Plan also says that the comprehensive oral evaluation is allowed two
times per year, and you have reached this limit.
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, cone beam CT capture and
interpretation (D0367) and caries risk assessment and documentation (D0602) are not among those covered
under this benefit. The contract says that comprehensive oral evaluation (D0150) and is limited to 2 of either
codes D0120 or D0150 per calendar year, and 1 comprehensive oral evaluation (D0150) per 3 calendar years.
The record shows that you received a comprehensive oral evaluation (D0150) on April 14, 2021, and April 22,
2021, and you have exceeded your limit of 2 per 1 calendar year. Therefore, we decided that the Plan does not
have to pay for the cone beam CT capture and interpretation (D0367), caries risk assessment and
documentation (D0602), and comprehensive oral evaluation (D0150) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
November 20, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on November 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission provided from January 19, 2020, to February 7, 2020.
You asked the Plan to waive the copayment for the inpatient admission. You say that you disagree with the $1,575 copayment for two days. The Plan denied your request. The Plan says you have been asked to pay 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 $225 copayment per day, days 1-7 and a $0 copayment per day, days 8-90 for each medically necessary covered inpatient stay. You have been asked to pay a $1,575 copayment for the inpatient admission. ($225 x 7 = $1,575). The inpatient admission falls within the "Inpatient hospital care" benefit category. The medical record shows you were admitted on January 19, 2020 and discharged on February 7, 2020.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient admission provided from January 19, 2020, to February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on November 30, 2020.
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that the service at issue was incorrectly ordered as non-preferred. You want the preferred pricing. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment for each visit for Medicare-covered services in a non-preferred (hospital based) radiological facility. You have been asked to pay a $250 copayment for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis 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. 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 CT scan of the abdomen and pelvis (74177) provided on November 30, 2020.
Your complaint about the provider ordering a CT scan at a non-preferred facility 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) provided on March 12, 2021.
You asked the Plan to pay for a shingles vaccine. You say that your first dose of this vaccine was covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine. Therefore, we decided that the Plan does not have to pay for a Zoster (shingles) vaccine (90750) provided on March 12, 2021.
Benefits for a shingles vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96413) provided on February 2, 2021.
You asked the Plan to pay for chemotherapy administration. You say that this has been paid in the past. The Plan denied your request. The Plan says this was not billed correctly.
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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT code 96413 is not supported in the medical record. Specifically, the records show that this code was used to bill for an Actemra infusion. Actemra is not considered to be a chemotherapy agent. Based on
this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96413) provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay from January 5 through January 7, 2021.
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you would like the Plan to pay an additional amount for the requested services. The Plan denied your request. The Plan says the correct cost share has applied to the claim.
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 Inpatient Hospital Care.
You have been asked to pay $2,427 in coinsurance for the inpatient hospital stay. This amount is less than the 20% coinsurance required by the Plan for Inpatient 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 coinsurance for the inpatient hospital stay from January 5 through January 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 28 through February 5, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you disagree with the copayment you are being charged. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $395 copayment per day for days 1 - 5 for Inpatient Hospital Care. You have been asked to pay $1,975.00 in copayments ($395 per day for days 1 - 5, and $0 for days 6 -8) for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the inpatient hospital stay from January 28 through February 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from May 27, 2020, to May 29, 2020.
You asked the Plan to pay for the medical services. You say that the enrollee did not pay anything to the facility at the time of service, so you do not have the proof of payment. The Plan denied your request. The Plan says proof of payment was not received.
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United States are excluded from coverage except for the services listed above. We looked at the file and Medicare rules. Since the Plan has not received proof of payment from the beneficiary, the Plan cannot make reimbursement at this time. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided from May 27, 2020, to May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series of radiographic images (D0210) and the additional tooth to the partial denture (D5650) provided on March 15, 2021.
You asked the Plan to pay for the dental services. You say that you would like reconsideration because your provider only rendered services that were needed and these services should be covered twice per year. The Plan denied your request. The Plan says you have exceeded the frequency limit for the comprehensive oral evaluation (D0150) and the complete series of radiographic images (D0210) and the additional tooth for the existing partial denture 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.
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. Specifically, the record indicates that you received the comprehensive oral evaluation (D0150) and the complete series of radiographic images (D0210) on October 6, 2020. These services are covered by the Plan once every three years. Additionally, the additional tooth for the existing denture is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete series of radiographic images (D0210) and the additional tooth to the partial denture (D5650) provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive metabolic panel, lipid panel, glycated hemoglobin, and complete blood count testing provided on July 15, 2020.
You asked the Plan to pay for the lab testing. You say that these tests were medically necessary and should be covered. The Plan denied your request. The Plan says this claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not support that this sample was taken directly by the laboratory. As such, use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive metabolic panel, lipid panel, glycated hemoglobin, and complete blood count testing provided on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on January 11, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for a seat lift mechanism. You say that you were never told that you needed to go to an in-network provider to obtain the supplies at issue. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) provided on January 11, 2021, by a supplier not enrolled in the Medicare program.
Your complaint about receiving erroneous or incomplete information about your benefits from a representative of the Plan 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee experiences relief in flexion. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.
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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services (92060, 92014) provided on March 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OON ophthalmological services. You say that these services should be covered. The Plan denied your request. The Plan says these 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 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 ophthalmological services (92060, 92014) provided on March 15, 2021 by an out-of-network (OON) provider.