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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member needs daily oversight by a physician and interdisciplinary therapy care. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 surgical
repair of a hip fracture after a fall. The enrollee's medical problems 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. While the documentation
does support a need for physical and/or occupational therapy, there is no documented need for a intensive,
multi-disciplinary 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided on April 13, 02021 by an out-of-network (OON) provider.

You asked the Plan to pay for x-ray services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 x-ray services provided on April 13, 02021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a 3-dimensional(3D) rendering (76377) provided on January 4, 2021.
You asked the Plan to pay for a 3D rendering. You say that these services were appropriate for the enrollee's condition. The Plan denied your request. The Plan says this cannot be paid separately.
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, we have confirmed that code 76377 has a bundled relationship with code 93922 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a 3-dimensional(3D) rendering (76377) provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental adjunctive pre-diagnostic testing (code D0431) and
application of fluoride varnish (D1206) provided on April 7, 2021.
You asked the Plan to pay for dental services. You say that this dental work is important to you but you are on
a limited income. The Plan denied your request. The Plan says these services are not covered by the Plan's
dental 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 dental adjunctive pre-diagnostic testing (code D0431) and application of fluoride varnish (D1206) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 19, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the skilled nursing facility is also out-of-network.
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 skilled nursing services provided on November 19, 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 acupuncture services provided on March 4, 2021 to March 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for acupuncture. You say that you were told that acupuncture might be helpful, and assumed that this provider accepted your plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 acupuncture services provided on March 4, 2021 to March 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat CESI C7.

You asked the Plan to pre-approve a repeat CESI C7. You say that you hope this CESI will reduce the enrollee's daily chronic pain and improve her overall quality of life. The Plan denied your request. The Plan says the physician notes do not say if the enrollee has problems forming blood clots, the pain did not get better with medicine or physical therapy did not help, arms are weak, pain down arm, or reflexes are not normal.

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 a repeat CESI C7. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found epidural injections are considered medically necessary for management of persons with radiculopathy when the patient has a dermatomal pattern of pain that corresponds with the level requested. The clinical information provided does not meet this criterion and, therefore, the requested injection is not indicated at this time. The review indicates that the services at issue in this case are not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a repeat CESI C7 have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat CESI C7.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (87340) provided on February 1, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation does not show why the services were provided.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without supporting records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab services (87340) provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on March 8, 2021.

You asked the Plan to pay for the pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 the pathology services are not supported in the medical record. Specifically, these services were billed with modifier 26. The concepts of professional and technical components do not apply to procedure codes with a "0" indicator, as these services cannot be split into professional and technical components. Since a separate reimbursement cannot be issued, payment for the provided service must be obtained from the facility.

Based on this information, we decided that Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extractions provided on March 2, 2021.
You asked the Plan to pay more for the extractions. You say that you would not pay for insurance that you
could not use at the dentist you've been seeing for years. The Plan denied your request. The Plan says your
benefit for extractions was exhausted with the processing of this claim.
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, you also have a maximum benefit of
two extractions per calendar year. The Plan paid 50% for two extractions provided on March 2, 2021, which
exhausted your benefit.
Service Allowed Amount Coverage Member Liability
Extraction $163 50% $81.50
Extraction $163 50% $81.50
Extraction $200 Benefit Exhausted $200
TOTAL: $363
Therefore, we decided that the Plan does not have to pay more for the extractions provided on March 2, 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.
You asked the Plan to pre-approve IRF care. You say that you believe that you need intensive therapy in order to recover. The Plan denied your request. The Plan says you do not require frequent oversight by a physician or three hours of daily therapy.
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 was treated in the hospital on 8/5/2021 due to an open tibial/fibular fracture. He underwent open reduction and fixation (ORIF) surgery. As of 8/9/2021, the enrollee was
ambulating with therapy. He requires minimal assistance to stand up and for walking up to 100 feet with a rolling walker. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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 for physician services provided on May 1, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on May 1, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on March 4, 2021.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that a dark spot was found on a previous mammogram and you feel that because the mammogram was ordered by medical professionals that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $80 copayment for diagnostic mammograms provided in an outpatient hospital facility.

You received a diagnostic mammogram at an outpatient hospital facility on March 4, 2021. Therefore, you are responsible to pay the $80 copayment. 

You have been asked to pay an $80 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), adjunctive pre-diagnostic test (D0431), intraoral, periapical, first radiographic image (D0220), and intraoral, periapical, each additional radiographic image (D0230 x3) provided April 20, 2021.

You asked the Plan to pay for the fluoride varnish, adjunctive pre-diagnostic test, and periapical x-rays. You say that your dentist told you the services would be covered. The Plan denied your request. The Plan says the 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 topical application of fluoride varnish (D1206), adjunctive pre-diagnostic test (D0431), intraoral, periapical, first radiographic image (D0220), and intraoral, periapical, each additional radiographic image (D0230 x3) provided April 20, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay the balance for the complete dentures provided on April 13, 2021.
You asked the Plan to pay the balance for the complete dentures. You say that the provider told you the Plan would pay 100% and you do not have the money for the balance. The Plan denied your request. The Plan says you have a $1000 dental annual maximum which was paid to the provider.
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 complete dentures when the services are medically necessary and reasonable. We looked at the file and Medicare rules. You have a $1000 dental annual maximum which the Plan paid. Therefore, we decided that the Plan does not have to pay the balance for the complete dentures provided on April 13, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for adjustable gastric band procedure provided on March 11, 2021.
You asked the Plan to pay for adjustable gastric band. You say that this adjustment was required due to you losing weight. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that adjustable gastric banding is not covered by Medicare.
We looked at the file and Medicare rules. This service is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of adjustable gastric band have not been met. Therefore, we decided that the Plan does not have to pay for adjustable gastric band procedure provided on March 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0157, G0299, Q5001) provided September 6, 2020 to October 5, 2020.

You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 find that CPT codes G0157, G0299, & Q5001 are not supported in the medical record. Specifically the first visit date billed does not match the dates of service on the claim. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0157, G0299, Q5001) provided September 6, 2020 to October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 11, 2021, by an OON provider.
You asked the Plan to pay for the tooth extraction. You say that you should not be responsible for the cost because the provider failed to tell you prior to the service that they were not in-network. The Plan denied your request. The Plan says the services are not covered because they were rendered by an OON provider.
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 tooth extraction when the services are provided in-network. Out-of-network, you pay 100% of the cost of tooth extractions.
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 11, 2021, by an OON provider.