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

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued inpatient services from July 9, 2021, were requested. 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 continued services. Our physician reviewer found that it was not expected you would improve in a reasonable period of time beyond the dates in question. You were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors.
You were compliant with treatment and were having no side effects to the medication. You were occasionally going to group. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on October 3, 2020.
You asked the Plan to pay for the evaluation and management service. You say that the charge for discharge is valid as the enrollee signed on to hospice. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on October 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428) received December 31, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the hospital staff recommended ambulance transportation from the hospital back to your nursing home. 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 $225 copayment for Ambulance Services. You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 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 copayment for the ambulance transportation (A0428) received December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87631 provided on August 10, 2020.
You asked the Plan to pay for the laboratory 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 supported by the documentation.
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 87631 is infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We find that CPT code 87631 is not supported in the medical record. Specifically, the submitted documentation indicates that more than five targets were performed. There is a more appropriate code to describe the services provided. In addition, Respiratory viral panels of six or more pathogens are non-covered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87631 provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a MyoPro myoelectric upper limb orthosis.
You asked the Plan to pre-approve myoelectric orthosis. You say that traditional rehabilitation strategies have been tried and failed, and the MyoPro would effectively replace the enrollee's left elbow while restoring its strength and range of motion. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this device is considered to be experimental/investigational.
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 myoelectric orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke in 2018 resulting in upper left arm partial paralysis. The records from the ordering physician do not establish the medical reasonableness or necessity of this item.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myoelectric orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a MyoPro myoelectric upper limb orthosis
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (D3330), or pay an additional amount for the resin-based composite - one surface, posterior (D2391) received March 10, 2021 from the out-of-network provider.
You asked the Plan to pay for the endodontic therapy, and the resin-based composite. You say that you would like the Plan to pay more for these services. The Plan denied your request. The Plan says there's no coverage for endodontic therapy. Payment for the resin-based composite was calculated based on the Plan's average negotiated in-network fee schedule (INFS) in your area.
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, endodontic therapy is not among those covered under this benefit. The Plan covers restorations, two codes per calendar year, with 55% coinsurance when received from an out-of-network provider. If you receive services from an out-of-network provider, you may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. The Plan's allowed amount for the filling is $82.00. You are responsible for 55% of the cost ($45.10). In addition, the out-of-network provider may bill you for the difference between the Plan's allowed amount and what was billed by the out-of-network provider. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, molar tooth (D3330), or pay an additional amount for the resin-based composite - one surface, posterior (D2391) received March 10, 2021 from the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided on January 7, 2021.
You asked the Plan to waive the copayment for debridement. You say that you get your toenails clipped and disagree with 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 a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received debridement on January 7, 2021, at an outpatient hospital facility. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for debridement. Debridement falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 debridement provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on December 8, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not told that you would owe such a high amount and feel that the charges are incorrect. 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on December 8, 2020. The total allowed amount is $5,138.47 and 20% of that is $1,057.12. You have been asked to pay the total coinsurance amount of $1,057.12 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on June 2, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient observation and an X-ray provided from January 4, 2019, to February 16, 2019.
You asked the Plan to waive the copayments for outpatient observation and an X-ray. You say that you were admitted to the hospital and should not owe a copayment and you were not informed that you would owe a copayment for an X-ray. 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 a $350
copayment for outpatient observation. Your contract with the Plan also clearly says that you must pay a $45 copayment for X-rays. You received outpatient observation from January 4, 2019, to January 5, 2019. Therefore, you are responsible to pay the $350 copayment. You received an X-ray on February 16, 2019. Therefore, you are responsible to pay the $45 copayment. The total amount you owe is: $395. You have been asked to pay the total copayment amount of $395 for outpatient observation and an X-ray. Outpatient observation falls within the outpatient hospital services benefit category. An X-ray 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 copayments for outpatient observation and an X-ray provided from January 4, 2019, to February 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided February 22, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you should have a $0 copayment for a routine eye exam. The Plan denied your request. The Plan says the eye exam was medical in nature and therefore the $20 copayment was assessed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for an eye exam to diagnose and treat diseases and conditions of the eye.
You have been asked to pay a $20 copayment for the medical eye exam. We reviewed the medical records and determined that the Plan correctly assessed that the eye exam was considered medical in nature. The medical eye exam falls within the vision 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 for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out-of-network cost share for the core build up (D2950) and amalgam (D2150) provided on October 26, 2020.
You asked the Plan to waive the out-of-network cost share for the dental services. You say that you paid $90 on the date of service. You say that you received a bill for $60. You say that you were not informed previously that you would owe more than the $90 you paid initially. The Plan denied your request. The Plan says the provider in this case does not participate with the Plan. The Plan says that non-participating providers may bill you for any amount greater than the plan paid.
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, non-participating providers may bill you for any amount greater than the plan paid. Therefore, we decided that the Plan does not have to waive the out-of-network cost share for the core build up (D2950) and amalgam (D2150) provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair (K0001) with an elevating leg rest (K0195) and commode (E0165).
You asked the Plan to pre-approve a standard wheelchair with elevating leg rest and commode. You say that you need this item. The Plan denied your request. The Plan says you have previously received this same wheelchair with elevating leg rest and commode, this is considered a duplicate request and not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a standard wheelchair with elevating leg rest and commode. This serves the same purpose as the standard wheelchair with elevating leg rest and commode they already have. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001) with an elevating leg rest (K0195) and commode (E0165).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 23, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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
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 January 23, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on January 28, 2021.
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 physical therapy services. 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 physical therapy services provided on
January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 2, 2020.
You asked the Plan to pay for foot orthotics. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 2,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence garment, any type (A4520).
You asked the Plan to pre-approve incontinence supplies. You say that you have Parkinson's disease as well as prostate cancer that has caused urinary incontinence. You are currently purchasing the pads out of pocket. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garment, any type (A4520).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs (J3490) provided on June 18, 2020.
You asked the Plan to pay for drugs. You say that this was medically necessary. The Plan denied your request. The Plan says this code is not supported.
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 J3490 is unclassified drugs.
We find that CPT code J3490 is not supported in the medical record. Specifically, a description of what this unclassified code is being used to report, and there are no medical records to support its used. Based on this information, we decided that Medicare rules for coverage of drugs have not been met. Therefore, we decided that the Plan does not have to pay for drugs (J3490) provided on June 18, 2020