Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a sleep study.

You asked the Plan to pay for the sleep study. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the sleep study. 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 a sleep study.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for diarrhea and abdominal pain. Her medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) provided by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy. You say that the hospital facility failed to verify eligibility and obtain proper authorization for this service. You do not feel you should be held responsible for this error. The Plan denied your request. The Plan says they do not cover out of network services, except in limited circumstances. The services were not urgent, nor were they pre-approved. The out of network provider or facility is responsible for verifying eligibility and obtaining prior authorization prior to 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90837) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309)
rendered by the OON provider.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs.

You asked the Plan to pay for self-administered drugs. You say that you do not understand why these drugs were not covered. The Plan denied your request. The Plan says the denial of payment for these drugs is correct, because these self-administered drugs are not covered by the Medicare Part B and may be covered by the enrollee's Medicare Part D prescription drug benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs.

Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for preventive dental service billed with dental code D1999.

You asked the Plan to pay for dental service. You say that this service is covered by your dental benefits. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because dental code
D1999 is not covered by the Plan's dental 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.

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
preventive dental service billed with dental code D1999.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available and requires authorization for
certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent
situation that has been documented.

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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for the physician's services.
Therefore, we decided that the Plan does not have to pay for physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT.

You asked the Plan to pay for the cone beam CT (D0367). You say that you did not know the CT was not covered. The Plan denied your request. The Plan says specialized techniques are not benefits of the dental 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. Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367) is not covered. You can find this information in the Plan's 2020 Dental Processing Policies Manual.

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. Medicare does not cover cone beam CT D0367. Therefore, we decided that the Plan does not have to pay for the cone beam CT.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical first x-ray (D0220) intraoral periapical
additional x-ray (D0230 x5).

You asked the Plan to pay for the dental x-rays. You say that you live on social security and pay your dental
every month. The Plan denied your request. The Plan says this service is not covered under the plan 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. The health plan contact on
page 4-58 specifically says that any services not listed is not covered.

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 intraoral
periapical first x-ray (D0220) intraoral periapical additional x-ray (D0230 x5).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider.

You asked the Plan to waive the copayment for an ambulance trip. You say that you would like this paid by the Plan. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services.

You have been asked to pay a $250 copayment for an ambulance trip. The correct copayment has been applied to the services that were provided. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider.

You asked the Plan to pay for the outpatient clinic visit. The Plan denied your request. The Plan says services should be received from network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that you would owe a 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 20% coinsurance for Medicare Part B prescription drugs. 

You received a Medicare Part B drug. The allowed amount is $236.76 and 20% of that is $47.35.

You have been asked to pay the total coinsurance amount of $47.35 for a Medicare Part B drug. A Medicare Part B drug 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 a Medicare Part B drug.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a gingival irrigation (D4921).

You asked the Plan to pay for the gingival irrigation. You say that the services were medically necessary. The
Plan denied your request. The Plan says the procedure at issue is not a covered service under your dental
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. Therefore, we decided that the Plan does not have to pay for a gingival
irrigation (D4921).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the revision or removal of peripheral
neurostimulator electrode (64585).

You asked the Plan to waive the copayment for the surgical procedure. You say that this was a follow up
surgery to correct an issue with previous surgical procedure. Because the original surgery was the cause of the
issue, you feel it is unfair to ask you to pay for the second procedure to correct the first. The Plan denied your
request. The Plan says although you were unsatisfied with the quality of care you received, the provider did
render services to you and is allowed to bill for the provided services. Your concerns regarding the service you
received will be reviewed separately, however the $325 copayment was correctly applied to the billed surgical
procedure.

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 $325
copayment for outpatient surgery.

You have been asked to pay a $325 copayment for the surgical procedure. A second surgical procedure was
provided, and the provider is allowed to bill for the services rendered. 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 revision or removal of peripheral neurostimulator electrode (64585).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had COVID-19 and 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 $150 copayment for days 1-5 for inpatient hospital care.

You had an inpatient hospital stay. Therefore, you are responsible to pay $300, which is less than the total copayment amount.

You have been asked to pay $300 for an inpatient hospital stay. An 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 an inpatient hospital stay.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery.

You asked the Plan to waive the copayment for cataract surgery. You say that you already paid the surgery copayment and 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 $50 copayment for specialist services.

You have been asked to pay a $50 copayment for cataract surgery. Cataract surgery falls 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 copayment for cataract surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection.

You asked the Plan to waive the coinsurance for the denosumab (Prolia) injection. You say that you cannot afford the coinsurance amount. 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 20% coinsurance for Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the denosumab (Prolia) injection. The denosumab (Prolia) injection falls within the 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 the denosumab injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunizations.

You asked the Plan to pay for the Tdap and Hepatitis A vaccines. You say that you would like the Plan to pay for the vaccines. The Plan denied your request. The Plan says the vaccines are not covered by Medicare or the Plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap and Hepatitis A vaccines. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Tdap and Hepatitis A vaccines. Therefore, we decided that the Plan does not have to pay for the immunizations.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95811 and 94660 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 95811 is polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist. The definition of code 94660 is continuous positive airway pressure ventilation (CPAP), initiation and management.

We find that CPT codes 95811 and 94660 are not supported in the medical record. Specifically, there is no documentation of a polysomnography with four or more additional parameters of sleep to support code 95811. There is no documentation of CPAP ventilation initiation and management to support code 94660. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services.