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

We decided that the Plan does not have to waive the coinsurance for the dental cleaning (D1110) and the oral exam (D0120) provided on October 5, 2020.

You asked the Plan to waive the coinsurance for the cleaning and evaluation. You say that you do not understand why you were only reimbursed for half of what you paid your dentist. You cannot afford this bill. The Plan denied your request. The Plan says routine dental services, such as oral evaluations and teeth cleanings, require 50% coinsurance.

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 50% coinsurance for oral exams and cleanings. 

You have been asked to pay 50% coinsurance for the cleaning and evaluation. You paid $110 at the time of service, and the Plan reimbursed you $55 ($110 x 50% coinsurance = $55). 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 dental cleaning (D1110) and the oral exam (D0120) provided on October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral device/appliance used to reduce upper airway collapsibility (E0486) provided on November 20, 2019, by an OON provider.
You asked the Plan to pay for an oral device/appliance. You say that the requested device is a medical necessity for you. The Plan denied your request. The Plan says rules for payment have 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 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 an oral device/appliance used to reduce upper airway collapsibility (E0486) provided on November 20, 2019, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) provided January 25, 2020.
You asked the Plan to pay for the critical care services. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the billed service.
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 99291 is evaluation and management of the critically ill or critically injured patient, first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation did not include documentation of critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes. The plan had made multiple attempts to obtain the additional information from the provider. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided January 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $260 copayment charged for ambulance transport provided on November 11, 2020.
You asked the Plan to waive this copayment. You say that you stated that you were transported from the emergency room to another hospital for admission treatment. You feel you should not have a copayment for this transport. The Plan denied your request. The Plan says this copayment was charged based on the services provided and your Plan contract agreement.
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 $260 copayment for each one-way ambulance transport. 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 $260 copayment charged for ambulance transport provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and consultation provided on April 10, 2020.
You asked the Plan to pay for the extraction and consultation. You say that you believe these services should be covered because they were provided due to an emergency. The Plan denied your request. The Plan says the treating provider has opted out of Medicare effective November 23, 2013, to November 23, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.
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 covered when they are rendered by a provider that has opted out of Medicare. The record also shows that you made no contacts to the Plan prior to receiving the services in regard to your cost share or provider questions for the above referenced services. Therefore, we decided that the Plan does not have to pay for the extraction and consultation provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided on December 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that no pre-certification was required. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that the enrollee was seen for a catheter change. The provider in this case is not a network provider with the Plan. 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 home visit services provided on December 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206) provided on November 25, 2020.

You asked the Plan to pre-approve the topical application of fluoride varnish. You say that you believe payment for this service was denied in error. The Plan denied your request. The Plan says this service is not covered by 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. Therefore, we decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206) provided on November 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on December 8, 2020.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges because you were told you would not owe a copayment for the evaluation. 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 $30 copayment for outpatient rehabilitation services. You have been asked to pay a $30 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on December 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on July 24, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim cannot be paid as the type of bill code submitted was incorrect.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim cannot be paid as billed due to an issue with the type of bill code submitted on the claim. The Plan states a corrected claim would be reviewed if submitted. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker (E0143).

You asked the Plan to pre-approve a walker. You say that you require a walker to get around, and that your balance isn't good. The Plan denied your request. The Plan says DME items require a written order or prescription as a condition of coverage.

The Plan must follow Medicare rules. Medicare rules say that DME items require a written order/prescription from the treating practitioner for Medicare payment as a condition of payment. The documentation does not contain an order from any physician or practitioner for any type of walker. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a walker (E0143).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210).
You asked the Plan to pay for the complete series of radiographic images. You say that the requested service should be covered. The Plan denied your request. The Plan says the requested service is not covered under your plan's supplement 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 the intraoral - complete series of radiographic images (D0210).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on December 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 imaging services provided on December 30, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses (V2781, V2750, V2760, V2025) purchased from an out-of-network provider on October 28, 2020.

You asked the Plan to pay for the eyeglasses. You say that the Plan should pay for these glasses because you had not exhausted your benefit yet. The Plan denied your request. The Plan says they do not cover vision services or eyewear received from an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from an in-network provider. 

We looked at the file and the Plan's rules. You purchased these glasses from an out-of-network provider, which is excluded from coverage under the Plan's supplemental benefit. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses (V2781, V2750, V2760, V2025) purchased from an out-of-network provider on October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee's broken leg and age warrant rehabilitation care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that 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 enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Complications included cardiac arrest. The enrollee 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.

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 21, 2020.
You asked the Plan to pay for the office visit. You say that the enrollee required the medical care received. You say that the enrollee was desperate for care and no other doctor was available. The Plan denied your request. The Plan says in-network providers were available.
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 office visit provided by an out-of-network provider on December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy (esophagogastroduodenoscopy or EGD).

You asked the Plan to pre-approve endoscopy. You say that your doctor is ordering this because he is not sure what is wrong. The Plan denied your request. The Plan says the documentation does not indicate that you have upper abdominal distress which has persisted despite an appropriate trial of therapy.

The Plan follows Medicare rules. Medicare rules state that diagnostic endoscopies are only covered for the evaluation of certain conditions. 

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 endoscopy. Our reviewer says that you do not meet the Medicare criteria for the requested endoscopy. Our physician reviewer found you have symptoms of right upper quadrant and epigastric pain with thickened gallbladder on imaging. You are anemic and there is no evidence of gastrointestinal bleeding or imaging suggestive of gastrointestinal pathology. There is no evidence of persistence of symptoms despite therapy nor is there evidence of reflux. The elements of Medicare coverage are not satisfied, and this procedure 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 endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper endoscopy (esophagogastroduodenoscopy or EGD).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled services are not needed to maintain function or prevent decline.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have any complex wound care or any other skilled nursing needs. Your functional level is unchanged from a recent SNF discharge. Currently, with your weight-bearing limitations do not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the inversion table provided on November 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the inversion table. You say that you would like to be reimbursed for the out-of-pocket expense for the inversion table. The Plan denied your request. The Plan says the provider is out of network and no prior was authorization 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 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 inversion table provided on November 12, 2020 by an out of network (OON) provider.