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

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided on December 18 to December 31, 2020.
You asked the Plan to waive the copayment for inpatient rehab care. You say that the enrollee had a seamless transfer with no discharge and readmission and that, on three similar prior scenarios, the enrollee was not charged an additional copayment for transfers. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for per day for days 1 to 5 for a Medicare-covered stay at a network hospital.
The contract also says that the enrollee's inpatient cost share will begin on day 1 each time the enrollee is admitted. The enrollee has been asked to pay $1,250, or a $250 copayment per day for days 1 to 5 of a hospital stay for inpatient rehab care. Inpatient rehab care falls within the "Inpatient hospital care" benefit category. A transfer to inpatient rehab constitutes a separate inpatient admission. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided on December 18 to December 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
December 5, 2020, to December 31, 2020.
You asked the Plan to pay for home health services. You say that this was billed correctly according to your
contract. The Plan denied your request. The Plan says this was not submitted with a type of bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim for
the services at issue was not billed with a valid type of bill code. Therefore, we decided that the Plan does not
have to pay for the home health services provided to the enrollee from December 5, 2020, to December 31,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, Hyperbiotics, and sales tax, or pay more for the periodic oral exam, prophylaxis, and bitewings provided on November 11, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, Hyperbiotics, and sales tax, and to pay more for the periodic oral exam, prophylaxis, and bitewings. You say that you would like to appeal these services. The Plan denied your request. The Plan says the first intraoral periapical x-ray, Hyperbiotics, and sales tax are not covered services. The Plan also says that you are responsible for a 50% coinsurance, plus the difference between the in-network fee schedule (INFS) and dentists' charged fees when visiting an OON dentist for the periodic oral exam, prophylaxis, and bitewings.
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 Medicare rules also say that Medicare does not make separate payment for sales tax. Though the Plan offers a dental benefit in excess of Medicare coverage, the first intraoral periapical x-ray, Hyperbiotics, and sales tax are not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance, plus the difference between the billed amount and allowed amount for periodic oral exams, prophylaxis, and bitewings that are received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, Hyperbiotics, and sales tax, or pay more for the periodic oral exam, prophylaxis, and bitewings provided on November 11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of benign lesion (D7410) on February 26, 2021.
You asked the Plan to pay for the excision of benign lesion (D7410). You say that you were misled about this service being covered. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the excision of benign lesion (D7410) on February 26, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The patient was admitted for C3-T1 laminectomy and fusion and was treated for deep vein thrombosis and pulmonary embolism after surgery. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) provided November 19, 2020.
You asked the Plan to pay for the bone replacement graft and alveoplasty. You say that you think these services should be processed under your medical benefits. The Plan denied your request. The Plan says the claims for this date of service have been reprocessed however these 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 bone replacement graft - retained natural tooth - first site in quadrant (D4263) and alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) provided November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), periodontal maintenance (D4910), and topical application of fluoride varnish (D1206) provided March 4, 2020 and July 16, 2020.
You asked the Plan to provide additional payment for the periodic oral exam, periodontal maintenance, and fluoride varnish. You say that you were told this insurance would cover your dental services. The Plan denied your request. The Plan says since your services were provided by an OON provider, you are responsible for 50% of the cost plus the difference between the Plan's allowed amount and the total cost. Additionally, periodontal maintenance and fluoride varnish are not covered benefits under your 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. The Plan covers 50% of periodic oral exams when provided by an OON provider. We looked at the file and Medicare rules. The Plan provided documentation showing that they covered 50% of the cost of the periodic oral exam. Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance and fluoride varnish are not among those covered under this benefit. Therefore, we decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), periodontal maintenance (D4910), and topical application of fluoride varnish (D1206) provided March 4, 2020 and July 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for total hip replacement provided on
December 13, 2020.
You asked the Plan to pay for the anesthesia. You say that you would like this claim to be reprocessed for
payment because you are not hospice based providers, and cannot bill hospice. The Plan denied your request.
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or
unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on December 6, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for
total hip replacement provided on December 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine fusion surgery for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no instability and no need for wide decompression with facetectomy.
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 the procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no spinal instability documented on the motion films. Fusion surgery cannot be
approved.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve spine fusion surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on February 23, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that this service is not periodontal, it is preventative maintenance and should be covered. The Plan denied your request. The Plan says this service was billed as periodontal scaling and root planing, which is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. The Plan denied your request. The Plan says you have used 36 one-way trips for the 2021 calendar year. The benefit limited is exhausted.
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 36 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 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem
focused (D0140) and intraoral - periapical first radiographic image (D0220) provided December 1, 2020.
You asked the Plan to provide additional payment for the limited oral exam and intraoral x-rays. You say that
your provider was supposed to check your insurance and you assumed they had. The Plan denied your request.
The Plan says since you used an OON provider you are responsible for the difference between the Plan's
allowed amount and the total cost billed.
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 limited
oral exam and intraoral x-rays when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the
Plan. The Plan has provided coverage for these services up to the MAC. You are responsible for difference
between the MAC and the total cost billed by the OON provider. Therefore, we decided that the Plan does not
have to provide additional payment for the limited oral evaluation - problem focused (D0140) and intraoral -
periapical first radiographic image (D0220) provided December 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician inpatient hospital care (99233) provided on April 22, 2020.
You asked the Plan to pay for the physician inpatient hospital care. You say that you submitted a correct claim to the Plan with CPT 99233. The Plan denied your request. The Plan says that CPT 99255 is not covered by CMS guidelines.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not addressed the Plan's review and decision for CPT 99233. Therefore, we decided that the Plan has to pay for physician inpatient hospital care (99233) provided on
April 22, 2020.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on July 24, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 physical therapy services provided on July 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 24, 2021.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy. 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 physical therapy provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92012) received December 8, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that this was a post-operation follow up visit and therefore no copayment should be applied. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 Physician/Practitioner Services. You have been asked to pay a $45 copayment for the eye exam. This eye exam falls within the Physician/Practitioner Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam (92012) received December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) breast, without
and/or with contrast material (77047).

You asked the Plan to pre-approve an MRI. You say that the enrollee is BRCA 1 positive. Please see attached
documentation. The Plan denied your request. The Plan says the records do not show results of prior picture
studies such as x-ray or ultrasound that show a reason this request is needed.

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 an MRI. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee is a 70-year-old male who is BRCA1 positive. The enrollee has no personal history
of breast cancer and did not have an inconclusive or suspicious finding on previous imaging or current
suspicious symptoms or PE findings to justify follow-up with MRI. There was insufficient support found in the
provided documentation for this test without the qualifying history to meet Medicare criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) breast, without and/or with contrast material (77047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alternating pressure-reducing mattress, for the enrollee.
You asked the Plan to pre-approve the DME. You say that even with group two (2) support surface in place, the enrollee's pressure ulcers reoccur. The Plan denied your request. The Plan says the enrollee previously had a wound to the pelvis, but the wound has resolved and is no longer active; therefore, the criteria was not met.
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 DME. Our physician reviewer found the requested alternating pressure reducing mattress does not meet the medically necessary criteria per Medicare's LCD: Pressure Reducing Support Surfaces - Group 2 (L33642). The documentation does not indicate that the enrollee has multiple stage two (2) pressure ulcers located on the trunk or pelvis which have failed to improve over the past month. The documentation does not indicate that the enrollee has large or multiple stage three (3) or four (4) pressure ulcer(s) on the trunk or pelvis or has had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past sixty (60) days. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve an alternating pressure-reducing mattress, for the enrollee.