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

We decided that the Plan does not have to pay forFundus photography with interpretation and report (99250) and frames and lenses provided on July 10, 2020.You asked the Plan to pay forfundus photography and eyeglasses. You say that the services should be covered.The Plan denied your request. The Plan says fundus photography is not a covered benefit and the cost share was applied correctly for frames and lenses.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 $200 toward the purchase and fitting of eyeglasses and pair of lenses or contacts per a calendar year. They do not cover fungus photography. We looked at thefile and the Plan's rules. Records indicate the Plan paid $200 towards you frames and or lenses, this means you are responsible for the difference. The fungus photography is not a covered benefit; this means you are responsible for the cost. Based on thisinformation, we decided that the Plan's rules for coverage of fundus photography and eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay forFundus photography with interpretation and report (99250) and frames and lenses provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided October 16, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the services rendered were 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee with a history of chronic alcohol abuse, hypertension, and diabetes who presented to the ER with complaints of nausea and vomiting. He stated that he had been drinking excessively the night before this evaluation prior to the onset of heartburn and vomiting.
He denied any chest pain, abdominal pain, cough or fever. On examination, he was alert and oriented. He was not tremulous and his behavior was stated to be normal. He was in the process of getting admitted for care when he became upset with the nursing staff and left AMA. The enrollee was on the hospital premises for 10 hours. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 pay for the acute inpatient hospital care provided October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for dental x-rays provided on July 2,
2020.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the dental
benefit coverage.
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 Plan contract clearly
states there is a coinsurance for basic services such as x-rays. Dental x-rays do not fall into the category of
"preventative" services. Therefore, we decided that the Plan does not have to waive the cost share charged for
dental x-rays provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gingival irrigation (D4921) for all 4 quadrants provided on August 10, 2020.You asked the Plan to pay forthe gingival irrigation for all 4 quadrants. You say that a plan representative advised you should go to this provider. You say that you went to the dentist for a cleaning. You say that you were not aware of everything that the dentist did to you. You also say that you cannot afford to pay for these services.The Plan denied your request. The Plan says gingival irrigation is not 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 gingival irrigation is not among those covered under this benefit. The Evidence of Coverage specifically states that periodontal maintenance, gingival irrigation, and localized delivery of antimicrobial agents are not covered and the member is responsible for the additional charge.Therefore, we decided that the Plan does not have to pay forthe gingival irrigation (D4921) for all 4 quadrants provided on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound you had on July 2, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that you do not think it is fair that the Plan only paid a small portion of this bill.The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($112.09) is less than your copayment obligation, youare responsible for this full 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 $125 copayment for radiological diagnostic services. You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the radiological diagnostic 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 forthe ultrasound you had on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forvision care provided on May 14, 2020.You asked the Plan to waive the copayment forvision care. You say that you received a routine eye exam and should not be responsible for 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 $40 copayment for exams to diagnose and treat diseases and conditions of the eye for vision care. The record shows that you received vision care to diagnose and treat diseases of the eye on May 14, 2020. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for vision care. Vision care falls within the vision 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 inthe Plan.Therefore, we decided that the Plan does not have to waive the copayment forvision care provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve destruction by neurolytic agent; other peripheral nerve or branch (64640). You say that the procedures will provide the enrollee with long term pain control.The Plan denied your request. The Plan says bilateral sacroiliac joint (SI) radio frequency ablations have not been proven as effective as standard treatment of SI joint pain.

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 destruction by neurolytic agent; other peripheral nerve or branch (64640). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/ investigational because of the wide variation in efficacy in the peer-reviewed literature. Therefore, the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent; other peripheral nerve or branch (64640) have not been met.Therefore, we decided that the Plan does not have to pre-approve radio frequency ablation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on September 1,
2020.
You asked the Plan to waive the copayment for the lab services. You say that this test was needed in order to
pick up anti-anxiety medication, so you don't think you should have to pay a copayment. The Plan denied your
request. The Plan says you were charged this copayment 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 $10
copayment for lab services.
You have been asked to pay a $10 copayment for the lab services. This copayment applies regardless of the
reason for the lab test. 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 lab services you received on
September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator provided on June 12, 2020.
You asked the Plan to pay for the home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for the home ventilator provided on June 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the thoracentesis procedure you had at an outpatient hospital facility on June 24, 2020.
You asked the Plan to waive the copayment for the thoracentesis procedure. You say that you were told this provider was in-network and that this would be covered. The Plan denied your request. The Plan says this claim processed as in-network; however, this charge represents the applicable copayment for this 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 $320 copayment for surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $320 copayment for the thoracentesis procedure. The thoracentesis procedure falls within the surgery or other services provided to you at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the thoracentesis procedure you had at an outpatient hospital facility on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services provided from August 10, 2020, to August 24, 2020.
You asked the Plan to waive the copayments for laboratory services. You say that you should not owe anything for the laboratory services. 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 $5 copayment for laboratory tests. You received laboratory services from August 10, 2020, to August 24, 2020, for a total of 3 services. Therefore, you are responsible to pay the allowed amount of $3.48 per each service. The total amount you owe is: $3.48 (copayment) x 3 (laboratory tests) = $10.44. You have been asked to pay the total copayment amount of $10.44 for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for laboratory services provided from August 10, 2020, to August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehab to gain independent capacity. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The enrollee 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. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lancets provided from April 9, 2020 to July 8, 2020.You asked the Plan to pay forthe lancets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the documentation is missing required information.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof ofdelivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay forthe lancets provided from April 9, 2020 to July 8, 20
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional home health visits (120 home health visits total).
You asked the Plan to pre-approve 60 additional home health visits. You say that you need home health nursing care. The Plan denied your request. The Plan says rules for additional home health visits have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 60 home health visits. Our reviewer says that the services requested are not reasonable or medically necessary. Our physician reviewer found no required skilled nursing services or skilled therapy services are identified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 60 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 60 additional home health visits (120 home health visits total).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran intubation (31500) performed November 30, 2019.You asked the Plan to pay forthe intubation. You say that the services were medically necessary.The Plan denied your request. The Plan says the documentation does not support the procedure billed.The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 31500 is Intubation, endotracheal, emergency procedure.We find that CPT code 31500 is not supported in the medical record. Specifically, the provided records do not detail this procedure being performed. Many of the records were illegible. The plan requested additional documentation and none was received. Based on this information, we decided that Medicare rules for coverage of the intubation have not been met.Therefore, we decided that the Plan does not have to pay foran intubation (31500) performed November 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services rendered on April 21, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure codes 95907, 95886, 95999, and 95955 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 95907 is nerve conduction studies; 1-2 studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. The definition of code 95955 is electroencephalogram (EEG) during non-intracranial surgery (e.g., carotid surgery).We find that CPT codes 95907, 95886, 95999, and 95955 are not supported in the medical record. Specifically, there is no documentation of 1-2 nerve conduction studies to support code 95907. There is no documentation of needle electromyography to support code 95886. There is no documentation of an unlisted neurological or neuromuscular diagnostic procedure code support code 95999. There is no documentation of an EEG during non-intracranial surgery to support code 95955. 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 forthe testing services rendered on April 21, 2020.