Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for mental health services provided to the enrollee on September 11, 2020 and September 12, 2020 by two separate physicians.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that this is not covered based on the diagnosis code provided.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for metabolic encephalopathy. Based on a review of the records provided, it is noted that this enrollee had extreme confusion and unable to give a history. The enrollee was clearly in an altered mental status but was unable to sustain attention throughout the interview. She had limited spontaneity and minimal thought content/process. The treating psychiatrist was unable to determine suicidality. The enrollee was frequently visited by the training psychiatrist who made suggestions in treatment of this enrollee. It was noted that this enrollee did become aggressive and agitated requiring neuroleptic medication. Based on a review of the records, it does appear medically necessary and reasonable to have this enrollee evaluated by the psychiatrist.
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 services have been met. Therefore, we decided that the Plan has to pay for mental health services provided to the enrollee on September 11, 2020 and September 12, 2020 by two separate physicians.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance ride provided on June 27, 2020.
You asked the Plan to waive the coinsurance for the ambulance ride. You say that you should not have to pay because you have diabetes issues. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 40% of total cost for each out-of-network one-way Medicare covered trip. You have been asked to pay $208.32 which is 40% of the allowed amount for the ambulance ride. The allowed amount is $520.80. ($520.80 x 40% = $208.32). The ambulance ride falls within the "Ambulance 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 coinsurance for the ambulance ride provided on June 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional coverage for the custom fabricated abutment (D6057) provided June 11, 2020 and abutment supported porcelain/ceramic crown (D6058) provided November 19, 2020.

You asked the Plan to provide additional coverage for the custom fabricated abutment and abutment supported crown. You say that you have not used your $1,000 allowance for dental services in 2020. The Plan denied your request. The Plan says The Plan has already covered the $1,000 allowance and you are responsible for the remaining cost.

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 custom fabricated abutment and abutment supported crown up to a $1,000 allowance. Any amount above the $1,000 is your responsibility.

We looked at the file and Medicare rules. The Plan provided documentation showing they have issued your full $1,000 dental allowance. Based on this information, we decided that the Plan does not have to provide additional coverage for the custom fabricated abutment (D6057) provided June 11, 2020 and abutment supported porcelain/ceramic crown (D6058) provided November 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services after April 5, 2021.
You asked the Plan to pre-approve continuation of SNF services after April 5, 2021. You say that the enrollee needs additional SNF services. The Plan denied your request. The Plan says the enrollee appears to only need custodial services.
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 continuation of SNF services after April 5, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of May 6, 2021 the member did not require any skilled nursing or rehab services on a daily basis. The member was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As of April 6, 2021, the member only
required custodial services. The denial for further inpatient skilled care is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services after April 5, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services after April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided from January 8, 2020, to October 21, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that the copays should be reimbursed per the plan memo. The Plan denied your request. The Plan says the cost shares do not fall within the press release effective dates.
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 $30 copay for outpatient mental health care. The file shows that you received outpatient mental health care services on January 8, 2020, February 19, 2020, March 18, 2020, April 8, 2020, and May 6, 2020. A $30 copay was applied to each date of service. The services fall within the outpatient mental health care benefit category. These dates of service fall before the Plan's copay waiver. 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.
The file shows that you received mental health services on January 29, 2020. You also received office visits on June 10, 2020, June 17, 2020, and August 4, 2020. The Plan has confirmed that the copays for the services provided were refunded. We found no indication that would require the Plan to waive or further reimburse payment for these services. Based on the information provided, we decided that the Plan does not have to further pay for the medical services provided from January 8, 2020, to October 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on November 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there was not referral on file for these services.
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 had network providers available who could have provided 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 psychotherapy services provided on November 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and retreatment of previous root canal therapy - molar (D3348) provided October 22, 2020.
You asked the Plan to pay for the intraoral x-rays and retreatment of previous root canal. You say that you were in pain and did not think to check if the provider was in-network. The Plan denied your request. The Plan says you received services from an out-of-network provider and therefore the services are not covered.
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 intraoral x-ryas and retreatment of previous root canal when the services are provided by one of the Plan's dental vendor's Dental network providers. We looked at the file and Medicare rules. You were provided services by a provider who is not in the Plan's Dental network. The Plan had network providers available who could have provided 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. Based on this information, we decided that the Plan's rules for coverage of the intraoral x-rays and retreatment of previous root canal have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) and retreatment of previous root canal therapy - molar (D3348) provided October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) received from an out-of-network (OON) provider.
You asked the Plan to pay for the complete series of radiographic images. You say that this provider participates in the Plan's network. The Plan denied your request. The Plan says items and services received from an out-of-network provider are not covered.
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 Plan does not cover items and services received out-of-network. The Plan has confirmed that the provider in this case was not in-network on the date of service. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) received from an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for hot or cold pack therapy described by code 97010 provided on December 3, 2020.
You asked the Plan to pay for code 97010. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 97010 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for hot or cold pack therapy described by code 97010 provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy, 100 MG tablet.
You asked the Plan to pre-approve Ubrelvy. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy, 100 MG tablet.
Benefits for Ubrelvy may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 this is necessary to make sure you don't fall The Plan denied your request. The Plan says you can be treated 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. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (99214) provided on November 17, 2020.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because this claim was billed correctly. The Plan denied your request. The Plan says it is not appropriate to report left and right diagnosis codes when a more specific code is available.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99214 is not supported in the record. Specifically, this claim was billed with two diagnosis codes which indicate the right and left side. There is a more appropriate bilateral diagnosis code for these services. Based on this information, we decided that Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient visit (99214) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the submucous resection inferior turbinate (30140) provided on October 1, 2020.
You asked the Plan to pay for the submucous resection inferior turbinate. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 submucous resection inferior turbinate. Our reviewer says that CPT code 30140 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include sufficient documentation to validate a submucous resection inferior turbinate, partial or complete, any method bilaterally was performed on October 2020 base on the National Correct Coding Initiative Policy Manual description of 30140 50, therefore this procedure cannot verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the submucous resection inferior turbinate have not been met. Therefore, we decided that the Plan does not have to pay for the submucous resection inferior turbinate (30140) provided on October 1, 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 the enrollee will benefit from 24-hour nursing care. The Plan denied your request. The Plan says the denial of IRF service is correct.
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. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met in a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD or the MILD procedure).
You asked the Plan to pre-approve MILD procedure. You say that this treatment is clinically supported and medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is not enrolled in an approved clinical study for this procedure.
The Plan must follow Medicare rules. Medicare rules say that the MILD procedure is only covered for beneficiaries who are enrolled in an approved Coverage with Evidence Development (CED) clinical study. We looked at the file and Medicare rules. The Plan has confirmed that this enrollee is not currently enrolled in a Medicare approved CED study for the requested MILD procedure. Based on this information, we decided that Medicare rules for coverage of MILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD or the MILD procedure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on September 10, 2020.

You asked the Plan to pay for the crown. You say that The Plan denied your request. The Plan says they paid for part of the crown, but after a partial payment your $2,000 maximum allowance was exhausted for the year, and the remainder of the cost is your responsibility.

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, services in excess of the $2,000 annual maximum limit are your responsibility. The Plan provided documentation showing that they have already paid the full $2,000 maximum for the 2020 plan year. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 25, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network 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 did not pre-approve the physician's services. 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 physician's services provided on November 25, 2020.