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

We decided that the Plan has to pay forthe initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on September 10, 2020.You asked the Plan to pay forthe dental services. You say that your tooth was causing you pain. You say that food was getting caught and your gum was receding. You also say that your tooth was cracked.The Plan denied your request. The Plan says that the x-rays are covered once in a 12 month period. The Plan also says that the frequency limithas been exceeded.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 did not provided documentation to substantiate their claim that the frequency limit for the x-rays has been denied. Without documentation that shows when this service was paid for by the Plan, we cannot determine if the benefit has been exhausted.Therefore, we decided that the Plan has to pay forthe initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on September 10, 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 themistake 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: 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 IRF care is medically necessary. The Plan denied your request. The Plan says a lower level of care would be appropriate.
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. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network outpatient mental health care provided to the enrollee on May 20, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization or referral for out of network care.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 Plan contract also states outpatient mental health care requires a referral. The provider in this case is not a network provider with the Plan. The Plan has network providers available whocan provide the services at issue in this appeal. The Plan did not pre-approve the service 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 forout of networkoutpatient mental health care provided to the enrollee on May 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment (CPT Code 77085) provided on September 2, 2020.You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the submitted documentation supports 1 (one) unit of 77085-26, which was previously approved/paid. The Plan states there is no additional documentation supporting an additional study which was billed and remains denied. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Review of the available clinical case notes and records presented for an appeal of Dual-energy X-ray absorptiometry (DEXA), code 77085-26, for date of service September 2, 2020, has been completed. After reassessing the entire situation, the result is that the initial denial is upheld. The member had DEXA scan on September 2, 2020. The submitted documentation supports 1 (one) unit of 77085-26, which was previously approved/paid. There is no additional documentation supporting an additional study which was billed and remains denied. The reports submitted are duplicates of each other. This is a billing issue. Therefore, we decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment (CPT Code 77085) provided on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9338) provided to the enrollee on August 3, 2020.
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 this is an invalid procedure code for the services.
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 HCPCS code S9338 is "Home infusion therapy, immunotherapy (e.g., intravenous immunoglobulin, interferon);administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment drugs and nursing visits coded separately), per diem." This code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS S9338) provided to the enrollee on August 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health care provided to the enrollee on June 10, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 Plan contract also states a referral is required. The 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 foroutpatient mental health care provided to the enrollee on June 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency department visit on March 11, 2020.You asked the Plan to waive the copayment foran emergency department visit. You say that you would like your claim considered under the COVID-19 criteria.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). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit. The Plan's copayment waiver for COVID-19 patients does not apply to emergency care. You have been asked to pay a $90 copayment for an emergency department visit. An emergency department visit falls within the "Emergency 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 in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran emergency department visit on March 11, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gingival irrigation (D4921) provided on September 8, 2020.You asked the Plan to pay forthe gingival irrigation. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says your contract does not include coverage for the services received.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 forthe gingival irrigation (D4921) provided on September 8, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on February 20, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe lab services. You say that these services were provided in good faith.  You say that you know you are a non-plan provider, but you are requesting a one-time exception to have these services covered.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. 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 forthe lab services provided on February 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 on September 11, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapeutic procedures provided from August 26, 2019, to September 9, 2019.You asked the Plan to pay forthe therapeutic procedures. You say that the Plan should pay these claims.The Plan denied your request. The Plan says the submitted medical records did not include the time spent providing the specific services.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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility, 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.We find that CPT code 97110, 97112 is not supported in the medical record. Specifically, the time spent for each procedure is not in the treatment notes. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures have not been met.Therefore, we decided that the Plan does not have to pay forthe therapeutic procedures provided from August 26, 2019, to September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe urology services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON urology services. You say that this service is needed to avoid future infections and should be done soon.The Plan denied your request. The Plan says there is no reason that the services at issue cannot be provided in-network. They may be covered under the POS benefit.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this caseis not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe urology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen stand rack provided on August 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the oxygen stand rack. You say that your doctor told you that you needed this item. The Plan denied your request. The Plan says this item was not prior authorized and was neither ordered nor provided by a Plan provider.
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 provider in this case is not a network provider with the Plan. 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 oxygen stand rack provided on August 14, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab work provided by a participating provider on July 24, 2020.You asked the Plan to waive the deductible for lab work. You say that you do not agree with this deductible amount. The Plan denied your request. The Plan saysthe correct deductible amount has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests/in-network/labs. The item or service you asked thePlan to waive the deductible for falls within the benefit category outpatient diagnostic tests/in-network/labs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests/in-network/labs. This cost sharing is a contractual obligation that had not been met at the time lab work was received on July 24, 2020. The total deductible amount that is being asked to pay is $132.78. Therefore, we decided that the Plan does not have to waive the deductible for lab work provided by a participating provider on July 24, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on August 14, 2020.You asked the Plan to pay for the radiology services. The Plan denied your request. The Plan says Original Medicare would be responsible for paymentof all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge orrevocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated tothe terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit forthe dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for radiology services provided on August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan.  The Plan did not pre-approve the service 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 forthe medical services provided on August 10, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental cleaning (D1110), comprehensive oral evaluation (D0150), and panoramic X-ray (D0330) provided on August 17, 2020 by an out-of-network (OON) provider.You asked the Plan to pay forthe dental cleaning, comprehensive oral evaluation, and panoramic X-ray. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no benefits are available for procedures performed by OON providers.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental cleaning, comprehensive oral evaluation, and panoramic X-ray when the services are rendered by a provider that is contracted with the Plan's dental vendor. 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 networkproviders 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 Planto pay for these services.Based on this information, we decided thatthe Plan's rules for coverage of the dental cleaning, comprehensive oral evaluation, and panoramic X-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe dental cleaning (D1110), comprehensive oral evaluation (D0150), and panoramic X-ray (D0330) provided on August 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 forlimited oral evaluation -problem focused (D0140) provided on September 8, 2020.You asked the Plan to pay forlimited oral evaluation -problem focused. You say that the service should be covered.The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. You are allowed one limited exam to evaluate a problem per plan year.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. Specifically, records show you have already exhausted this benefit.Therefore,we decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140) provided on September 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you provided medically necessary services in good faith.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 forthe medical services provided on July 21, 2020 by an OON provider.