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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on December 12, 2020, to December 13, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should have been in 
observation, not inpatient. 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 $290 
copayment per day for days 1-5. There is a $0 copayment per day for days 6-90 for inpatient hospital care.  
 
You have been asked to pay a $290 copayment per day for days 1-5 for an inpatient hospital stay. The total 
amount you are being asked to pay is $290 for one night as an inpatient. The correct copayment has been 
applied to the services that were provided. 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 
provided by a participating provider on December 12, 2020, to December 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two limited, problem focused oral evaluations (D0140), 
periapical first radiographic image (D0220), porcelain/ceramic crown (D2740), and core buildup, including any 
pins when required (D2950) provided November 24, 2020, and November 25, 2020. 
 
You asked the Plan to pay for the two limited exams, periapical x-rays, crown and core buildup.. You say that 
the services should be covered. The Plan denied your request. The Plan says the services are not covered under 
your 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 the two 
limited, problem focused oral evaluations (D0140), periapical first radiographic image (D0220), 
porcelain/ceramic crown (D2740), and core buildup, including any pins when required (D2950) provided 
November 24, 2020, and November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0482) provided on July 13, 2020. 
 
You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that the Place of Service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face to-face service. 
 
We find that CPT code G0482 is not supported in the record. Specifically, the claim was billed with place of 
service code 81, indicating the specimen was obtained in a laboratory. The record indicates that the specimen 
was obtained in an office setting. There is a more appropriate place of service code for reporting. Based on this 
information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we 
decided that the Plan does not have to pay for the drug test (G0482) provided on July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 9, 2020. 
 
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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health services 
received from November 2, 2020 to November 24, 2020. 
 
You asked the Plan to waive the copayments for the outpatient mental health services. You say that you 
disagree with the amount owed. The Plan denied your request. The Plan says the claims have been processed 
correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $40 
copayment for each Medicare-covered individual therapy session.  
 
You have been asked to pay a $40 copayment for each of the outpatient mental health services. The outpatient 
mental health services fall within the outpatient mental health 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 copayments for the outpatient mental health services received from November 2, 2020 to 
November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve vision services. You say that you relay on the skilled nursing facility to 
obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by 
a participating provider or participating facility. 
 
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 
vision services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the low osmolar contrast material coded Q9966 provided on 
August 25, 2020. 
 
You asked the Plan to pay for the low osmolar contrast material. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 Q9966 is low osmolar contrast material, 200-299 mg/ml 
iodine concentration, per ml. 
 
We find that CPT code Q9966 is not supported in the medical record. Specifically, the documentation 
submitted did not include documentation that low osmolar contrast material, 200-299mg/ml iodine 
concentration, per ml was administered.  
 
Based on this information, we decided that Medicare rules for coverage of the low osmolar contrast material 
have not been met. Therefore, we decided that the Plan does not have to pay for the low osmolar contrast 
material coded Q9966 provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete 
series x-ray (D0210) provided on December 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that you went to this dentist to get a second opinion. 
You say that you did not feel comfortable with your previous dental office. You say you feel that they just 
wanted to get as much money out of you as they can. You say that the dental office makes you wait 45 minutes 
past your appointment time. You also say that this is why you chose to go to a new dental office. The Plan 
denied your request. The Plan says coverage for a comprehensive oral evaluation is limited to once every 3 
plan years. The Plan says that coverage for a complete series x-ray is limited to once every3 plan years. The 
Plan also says that the frequency limits for these services have been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral 
evaluation and complete series x-ray that you received on February 26, 2020. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete series x-ray 
(D0210) provided on December 2, 2020.  
 
Your complaint about the dental office charging you a lot of money and making you wait a long time 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair (K0813) provided September 2, 2020, 
by a provider not certified with Medicare. 
 
You asked the Plan to pay for the power wheelchair. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this provider is not certified with Medicare 
and not eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that you must receive your care from a provider 
eligible to participate in Medicare.  
 
We looked at the file and Medicare rules. In this case, the record shows this provider is not certified with 
Medicare. Based on this information, we decided that Medicare rules for coverage of the power wheelchair 
have not been met. Therefore, we decided that the Plan does not have to pay for the power wheelchair (K0813) 
provided September 2, 2020, by a provider not certified with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73610 provided on September 20, 
2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 73610 is radiologic examination, ankle; complete, 
minimum of 3 views. 
 
We find that CPT code 73610 is not supported in the medical record. Specifically, this code was billed with an 
appropriate anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the 
x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray 
services coded 73610 provided on September 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for the approved surgery.

You asked the Plan to pre-approve inpatient admission for the approved surgery. You say that the requested inpatient admission for the approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient admission for the approved surgery is 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 inpatient admission for the approved surgery. Our reviewer says that the requested inpatient admission for the approved surgery is not medically necessary. Our physician reviewer found the plan approved total knee arthroplasty (TKA) as outpatient. The TKA procedure may be performed safely with an observational 48 hour stay. Inpatient admission is not needed and is not the standard of care for this routine knee surgery. 

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 admission for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for the approved surgery.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide services.

You asked the Plan to pay for the home health aide. You say that the services were necessary. The Plan denied your request. The Plan says the provider in this case is not Medicare certified. The Plan also says that as a result, payment cannot be made.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health aide have not been met. Therefore, we decided that the Plan does not have to pay for the home health aide services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 has a past medical history of diabetes, osteoarthritis and back pain and is living at home. He has weakness and trouble ambulating. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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.

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computerized ophthalmic diagnostic 
imaging (92134) provided on October 9, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging. You say that you feel you 
should not have to pay the copay for this exam because you already have the copay for the office visit. The 
Plan denied your request. The Plan says that diagnostic imaging services are not included in your office visit 
copayment and have their own required cost-sharing. The cost sharing for the diagnostic exam was 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 $45 
copayment for each Medicare-covered exam to treat an eye condition.  
 
You have been asked to pay a $34.45 copayment for the ophthalmic diagnostic imaging. An ophthalmic 
diagnostic imaging service is considered an exam to treat or address an eye condition. 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 computerized ophthalmic diagnostic imaging (92134) provided 
on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care.

You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the continuation of inpatient mental health care is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care 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 pre-approve the continuation of inpatient mental health care. Our reviewer says that the continuation of inpatient mental health care is not medically necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while not showing any aggressive behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided this enrollee does not meet the criteria for continued acute inpatient mental health treatment as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations while not showing any threats to safety.

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 continuation of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the integrated biopsychosocial assessment (90791) provided 
July 29, 2019. 
 
You asked the Plan to pay for the integrated biopsychosocial assessment. You say that you did not receive 
proper notice of this enrollee's benefit determination, hence the untimely submission. The Plan denied your 
request. The Plan says this claim was received after the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for integrated biopsychosocial assessment was not filed until October 12, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the integrated biopsychosocial assessment (90791) 
provided July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on September 24, 
2020. 
 
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this 
testing is medically necessary. The Plan denied your request. The Plan says CxBladder Detect is not an 
approved test. 
 
The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0012M , non-
coverage was reaffirmed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder testing have not been met. Specifically, this testing is not a Medicare covered 
benefit. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M) provided 
on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services and procedures provided on 
October 22, 2020. 
 
You asked the Plan to pay for the ophthalmological services and procedures. The Plan denied your request. The 
Plan says the Plan requires the utilization of in-network providers unless the Plan pre-approves out-of-network 
services in non-emergent situations. 
 
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 
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 ophthalmological services and procedures provided on 
October 22, 2020.