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

We decided that the Plan does not have to pay for the full mouth x-ray (D0210) and the unspecified preventive service (D1999).

You asked the Plan to pay for the dental services. You say that you were advised to get the x-ray from your previous dentist. You say that you were told the x-ray was not clear. You say that the x-ray was too old. You also say that you needed to get a new x-ray done. The Plan denied your request. The Plan says 1 full mouth x-ray per calendar year is covered. The Plan says that the frequency limit for this service has been exceeded. The Plan also says that the unspecified preventive service is not listed as a covered service.

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 frequency limit of 1 full mouth x-ray per calendar year has been exceeded. The record shows that the Plan paid for a full mouth x-ray that you received. Additionally, the unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth x-ray (D0210) and the unspecified preventive service (D1999).
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 enrollee needs rehab. The Plan denied your
request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital with congestive heart failure. The physical therapy note states he needs assistance with bed mobility, standing up, and sitting down. He does not require the intensity of services provided in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), the root canal (D3330), and the pulp vitality test (D0460) provided on September 30, 2019.

You asked the Plan to reimburse you for the dental services. You say that you were advised by the dental office that the provider was out of network. You say that you did not think anything of it as your regular dentist is out of network too. You say that you were on the Plan's website and noticed that this provider was actually in network. You also say that you feel you should be reimbursed for the services and should not be penalized for not filing more timely. The Plan denied your request. The Plan says claims need to be submitted within 1 year of the date of service. The Plan says that the claim was not received until October 29, 2020, more than 1 year after the date of service.

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 the dental services was not filed until October 29, 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 reimburse you for the limited oral evaluation (D0140), the periapical x-ray (D0220), the root canal (D3330), and the pulp vitality test (D0460) provided on September 30, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a sleep study.

You asked the Plan to waive the copayment for sleep study. You say that the provider struggled with getting the machine to work, so you disagree with this copayment. The Plan denied your request. The Plan says that the copayment amount you are being charged is correct.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage for this date of service. We requested this information, but it was not submitted to us. Without the applicable Evidence of Coverage, we cannot determine whether any cost-sharing amount applies to a sleep study. Therefore, the Plan has not shown that its decision to ask you to pay $121.53 copayment for this sleep study is correct or justified according to the Plan contract. Therefore, we decided that the Plan has to waive the copayment for a sleep study.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for injection of a diagnostic or therapeutic agent into a spinal joint (64490).

You asked the Plan to waive or reduce the copayment for the spinal injections. You say that you paid a $50 copayment at the time of service and assumed that covered your total responsibility for the bill. The Plan denied your request. The Plan says outpatient surgical procedures are subject to a $275 copayment.

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 $275 copayment for outpatient hospital surgery and services.

You have been asked to pay a $275 copayment for the spinal injections. This spinal injection service is billed with a surgical code and falls within the outpatient hospital surgery and 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 or reduce the copayment for injection of a diagnostic or therapeutic agent into a spinal joint (64490).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care.

You asked the Plan to pay for inpatient care. You say that DRG 853 is supported. The Plan denied your
request. The Plan says that DRG 854 is supported instead of 853.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG. DRG 853 is defined as infectious
and parasitic diseases with operating room procedure with major complications or comorbidities.

In this case, you billed the services with DRG 853. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that the billed DRG is supported in this case. Our physician reviewer found the enrollee was a 73-year-old female
diagnosed with acute respiratory failure with hypoxia after arriving at the emergency department with confusion. Her oxygen saturation was 90%. She was diagnosed with kidney stones and sepsis. DGR of 853 was assigned. The records show her partial pressure of oxygen was less than 60 and her arterial oxygen partial pressure to fractional inspired oxygen ratio was less than 300. She required at least 2L/m of oxygen supplementation. Based on the above documentations, this patient appeared to meet the diagnosis of acute respiratory failure and, therefore, the DGR of 853 would is supported.

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 care have been met. Therefore, we decided that the Plan has to pay for
inpatient care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no history of osteoporotic fracture. There is no trial and failure of zoledronic acid. There is no indication in the records that zoledronic acid would likely be less effective and/or likely have adverse effects. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services.

You asked the Plan to pay for the dental services provided by an out-of-network provider. You say that you called the Plan and the agent gave you the name of this dental group. The Plan denied your request. The Plan says you did not go to a participating provider for your care and your plan has no out of network 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, enrollees must visit the preferred contracted dental office to utilize covered benefits. Therefore, we decided that the Plan does not have to pay for dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient service and Part B drug provided on September 29, 2020.

You asked the Plan to waive the cost share for the photodynamic therapy and Part B drug. You say that you cannot afford the cost share. The Plan denied your request. The Plan says you were charged the copayment and coinsurance 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 20% coinsurance for Medicare Part B prescription drugs and a $240 copayment for outpatient services. 

You have been asked to pay $240 copayment for the photodynamic therapy and 20% coinsurance for Part B drug. The photodynamic therapy falls withing the Outpatient Hospital Service and the 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 cost share for the outpatient service and Part B drug provided on September 29, 2020.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with COVID-19 pneumonia and respiratory failure and discharged home on March 9, 2021. The physical therapy evaluation on February 26, 2021 states she needs assistance with standing and sitting and walking 10 to 12 feet with a rolling walker. She needs moderate assist with transfers and maximal assist with grooming, bathing, dressing, and toileting. She does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the control nasal hemorrhage services coded 30901 provided on March 2, 2020.

You asked the Plan to pay for the control nasal hemorrhage services. 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 30901 is control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method. 

We find that CPT code 30901 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the control nasal hemorrhage services have not been met. Therefore, we decided that the Plan does not have to pay for the control nasal hemorrhage services coded 30901 provided on March 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services beyond February 5, 2021.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the continued services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF after hospitalization for chest pain. You received oral medications and had stable vital signs. You received physical, occupational, and speech therapy in the SNF. You need assistance with functional mobility, including walking 30 feet with a rolling walker. You need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services beyond February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eighty additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says this request exceeds the benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve eighty additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, prophylaxis, and preventive procedure.

You asked the Plan to pay for the periodic oral evaluation, bitewings, prophylaxis, and preventive procedure. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the treating provider opted out of Medicare. The Plan also says that you are responsible for services provided by privately contracted providers.

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 received by providers who have chosen to opt out of Medicare. The record also shows that the Plan representative you spoke with advised you that you could go to any licensed dentist who had not opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, prophylaxis, and preventive procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740) and core buildups, including any pins when required (D2950).

You asked the Plan to pay for the crowns and core buildups. You say that these services were preventive, and not cosmetic. The Plan denied your request. The Plan says these services are not covered benefits under your 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.

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 crowns (D2740) and core buildups, including any pins when required (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says the total hip arthroplasty is approved but the inpatient admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the inpatient admission is not medically necessary. Our physician reviewer found the enrollee is planned for a total hip arthroplasty (THA). All comorbidities other than hip pain related to the member's presenting problem, appear to be controlled. However, all of these co-morbidities will be evaluated and optimized prior to the scheduled non-emergent procedure. She is classified as an American Society of Anesthesiology PS 3 with moderate systemic disease that is non-life threatening. The records do not support that the enrollee will require at least two midnights of inpatient hospital care for the planned 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) 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 code 99284 is 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 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity.

We find that CPT code 99284 is not supported in the medical record. Specifically, there is no documentation of a Level 4 emergency department visit for evaluation and management. 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 emergency room (ER) services.