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

We decided that the Plan does not have to waive the copayment for an ambulance trip, inpatient hospital stay,
an x-ray and a skilled nursing stay provided by multiple participating providers on August 17, 2019 to
September 13, 2019
You asked the Plan to waive the copayment for an ambulance trip, inpatient hospital stay, an x-ray and a skilled
nursing stay. You say that you should not have to pay for this because you fell while at the hospital. The Plan
denied your request. The Plan says the correct copayments have 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 $150 copayment for ambulance services, a $200 copayment per day for days 1-5. There is a $0
copayment for additional days for inpatient hospital care, a $10 copayment for outpatient diagnostic tests/x-ray,
and a $0 copayment per day for days 1-9. There is a $20 copayment per day for days 10-20. There is a $155 per
day copayment for days 21-100 for skilled nursing facility.
You have been asked to pay a $150 copayment for an ambulance trip, a $200 copayment per day for days 1-5.
There is a $0 copayment for additional days for an inpatient hospital stay, a $10 copayment for an x-ray, a $0
copayment per day for days 1-9. There is a $20 copayment per day for days 10-20 for a skilled nursing stay. An
ambulance trip falls within the ambulance services/ benefit category, inpatient hospital stay
falls within the inpatient hospital care benefit category, an x-ray falls within the outpatient
diagnostic tests /x-ray benefit category and a skilled nursing stay falls within the skilled nursing
facility/Benefit category. The total amount you are being asked to pay is $1,380 ($1,000
inpatient stay + $150 ambulance + $10 x-ray and $220 skilled nursing stay = $1,380). This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for an ambulance trip, inpatient hospital stay, an x-ray and a skilled
nursing stay provided multiple participating providers on August 17, 2019 to September 13, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2751) on tooth #'s 23, 24, 25, and 26 provided on July 24, 2019.
You asked the Plan to pay for the crowns. You say that you received a letter from the Plan stating that they were not going to cover these services. The Plan denied your request. The Plan says this treatment is only covered when it is done because the tooth has decay. The Plan also says that this service was provided because the teeth are worn, and not because of decay.
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 covers the crowns when the services are medically necessary and reasonable. 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 the crowns. Our reviewer says that the crowns are not medically necessary. Our physician reviewer found it appears that tooth #25 has been treated with endodontic therapy, however there is no post-treatment x-ray to review. The teeth appear to have some wear to them from attrition; however, they do not appear to have any loss of structure from decay or fracture. Our reviewer found that if there is only an endodontic access on tooth #25, it is unlikely that it would require full coverage by way of a crown to properly restore. The Plan considers crown restorations on anterior teeth that have been damaged by decay or fracture. Our reviewer also found that there has been no damaged structure from decay or fracture seen on tooth #'s 23, 24, 25, and 26, and therefore no necessity for crown restorations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pay for the crowns (D2751) on tooth #'s 23, 24, 25, and 26 provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 9, 2019, and November 12, 2019.
You asked the Plan to pay for the services. You say that you were told this would be covered. The Plan denied
your request. The Plan says the services were not authorized.
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 has network providers
available who can provide 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 medical services provided to you by an out-of-network provider on
October 9, 2019, and November 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurofunctional testing (96020) provided on August 20, 2019.
You asked the Plan to pay for the neurofunctional testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the professional interpretation of a diagnostic test must be separately billed with modifier 26 by the interpreting physician.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 96020 is not supported in the record. Specifically, global billing for professional and technical components is only possible when the technical component and physician providing the professional component of the service are furnished in the same payment locality. The submitted claim does not indicate that these services were rendered in the same payment locality, so the professional component must be billed separately with modifier 26. Based on this information, we decided that Medicare rules for coverage of the neurofunctional testing have not been met. Therefore, we decided that the Plan does not have to pay for neurofunctional testing (96020) provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit (99336). You say that you would like reconsideration because this is a long standing patient and change of care is not an option. The Plan denied your request. The Plan says services were provided to the member without obtaining prior authorization and the member can and has been receiving primary care services from in-network, contracted providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 medical services provided on December 26, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ocrevus (Ocrelizumab).
You asked the Plan to pre-approve the Ocrevus (Ocrelizumab). You say that the Ocrelizumab has been an effective and tolerated treatment for the enrollee. You also say that stopping the treatment would place the enrollee at high risk for relapse and disability worsening. The Plan denied your request. The Plan says that the criterion is not met for the Ocrevus. The Plan also says that the records show that the enrollee has been on Ocrevus before and does not show that they have had improvement from this drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Ocrevus (Ocrelizumab). Our reviewer says that the Ocrevus (Ocrelizumab) is medically reasonable and necessary for the enrollee. Our physician reviewer found in general, the use of disease modifying therapies in multiple sclerosis is primarily to avoid disease progression (e.g. prevent relapses, lesion formation), rather than promoting "clinical improvement" in the underlying condition. Our reviewer found that there was no documentation that the enrollee had any relapses while on the requested medication. Nor was there any documentation that imaging studies showed new lesions since the start of this medication. Our physician reviewer also found that overall, that would suggest clinical efficacy of the requested medication and Ocrevus can be said to be safe and effective for the patient. 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 Ocrevus (Ocrelizumab) have been met. Therefore, we decided that the Plan has to pre-approve Ocrevus (Ocrelizumab).
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: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to partially pay for acute inpatient hospital care from May 24, 2019 through June 3, 2019.
You asked the Plan to pay for acute inpatient hospital care from May 24, 2019 through June 3, 2019. You say that the stay was medically necessary. The Plan says that the stay 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 for inpatient hospital care. Our reviewer says that the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. Care provided to the enrollee was complex and supported complex medical conditions. Inpatient hospital care was medically necessary and appropriate. A progress note dated May 29, 2019 notes the enrollee intravenous (IV) antibiotics will be complete on May 31, 2019. This date was adjusted in later notes without clear explanation. The enrollee had stable vital signs and laboratory studies. Inpatient care was not supported by the records after May 31, 2019. Starting on this day, there is no medical necessity for ongoing inpatient care May 31, 2019 through June 3, 2019. 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 partially met. We decided that the Plan has to pay for acute inpatient hospital care from May 24, 2019 through May 31, 2019. We also decided that the Plan does not have to pay for acute inpatient hospital care from June 1, 2019 through June 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an acute care hospital (ACH). You underwent adrenal surgery, which was itself difficult, and complicated by coronary artery disease (CAD) and respiratory disease. You received a tracheotomy and remain on a ventilator. You are noted to have a poor overall prognosis. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on December 10, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because these services were medically necessary.The Plan denied your request. The Plan says that the member did not stay 2 midnights and a medical need for inpatient care was not shown.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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient'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 been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on December 10, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you saw this doctor in 2018 and the claim was paid for. You say that this claim should be paid as well. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 has network providers available who can provide 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 office visit provided on December 27, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for allergy tests provided by a participating provider on November 4, 2019 to November 18, 2019.
You asked the Plan to waive the coinsurance for an injection. You say that you are being billed $56 incorrectly. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient diagnostic tests/diagnostic tests/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $560. The total amount you are being asked to pay is $112 ($56 x 2 visits = $112). An injection falls within the outpatient diagnostic tests/diagnostic tests/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for allergy tests provided by a participating provider on November 4, 2019 to November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three endodontic therapies, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on September 17, 2019. You asked the Plan to pay for the endodontic therapies and intraoral periapical x-rays. You say that the damage to your teeth was due to medical conditions. The Plan denied your request. The Plan says these services are not covered under 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 pay for the three endodontic therapies, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neuropsychological Testing Services.You asked the Plan to pre-approve Neuropsychological Testing Services. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 Neuropsychological Testing Services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is documentation of memory deficit in the presence of cognitive impairment, which supports a diagnosis of dementia. Such a detailed history, which includes the perspective of a family member, is the most important component of a diagnostic evaluation of dementia. When there is agreement between the history and the mental status examination, a diagnosis of dementia is strongly suggested. The Mini-Mental State Examination (MMSE) supports a diagnosis of mild cognitive impairment in this case. Neuropsychological testing would not be expected to provide additional differential diagnostic information. The documentation does not support that Neuropsychological Testing Services are medically reasonable and necessary in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neuropsychological Testing Services have not been met.Therefore, we decided that the Plan does not have to pre-approve Neuropsychological Testing Services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from June 17, 2019 to June 18, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was admitted for
persistent shortness of breath and atrial flutter. The Plan denied your request. The Plan says the care the
enrollee received is considered an observation level of care.
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 physician
reviewer found that the enrollee presented to the emergency department (ED) from her primary care
physician's office with atrial flutter. In the ED, her vital signs were stable and her physical exam was
unremarkable. She was admitted to telemetry, and continued on ASA and Xarelto. Her condition stabilized and
improved. She was discharged home with PCP follow-up. 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 to the enrollee from June 17, 2019 to
June 18, 2019.