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

We decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report (D7950), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), limited oral evaluation - problem focused (D0140), unspecified preventive procedure, by report (D1999), and removal of mandible cyst (21046) provided January 27, 2021.

You asked the Plan to pay for the osseous graft, surgical tooth extraction, limited oral exam, unspecified preventative procedure and removal of mandible cyst. You say that you would like the service covered because you cannot afford to pay this bill. The Plan denied your request. The Plan says the the osseous graft, surgical tooth extraction, unspecified preventative procedure and removal of mandible cyst are not covered under your dental benefits. Additionally, services provided out-of-network are not covered. The removal of mandible cyst is also being reviewed separately under your medical 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 Plan does not cover services when provided out-of-network. The requested provider in this case is not a network dental provider with the Plan. We found no exception that would require the Plan to pay for these items/services. Additionally, osseous grafts, surgical tooth extractions, unspecified preventative procedures and removal of mandible cysts are not among the covered services in your in-network dental benefits. Therefore, we decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report (D7950), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), limited oral evaluation - problem focused (D0140), unspecified preventive procedure, by report (D1999), and removal of mandible cyst (21046) provided January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the chiropractic services provided from January 13, 2021, to March 24, 2021 by an out-of-network provider.
You asked the Plan to reimburse you for the chiropractic services (98942). You say that you would like the Plan to reimburse you because you are on a fixed income. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network 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 service 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 the service. Therefore, we decided that the Plan does not have to reimburse you for the chiropractic services provided from January 13, 2021, to March 24, 2021 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 29, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you passed out and fell on the floor and hit your head on a chair and cut your elbow. You say that your girlfriend tried to pick you up, and you could not stand so she called 911. You say when the medics arrived, they checked you over and four medics helped you to stand up and walk a little and treated your elbow by bandaging it and determined you did not have a concussion. You say they said you were probably dehydrated from not eating or drinking for two days and it was not necessary to transport you to the hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on March 29, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.

Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient thyroid surgery you had from April 16, 2021, to April 17, 2021 at an outpatient hospital facility.
You asked the Plan to waive the copayment for the outpatient thyroid surgery. You say that this was supposed to be billed as an inpatient surgery because your doctor does not do this procedure on an outpatient basis. The Plan denied your request. The Plan says you were charged this copayment 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 $400 copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $400 copayment for the outpatient thyroid surgery. The medical records from this procedure do not show that you were admitted to the hospital as an inpatient. Rather, you were admitted to
the extended recovery unit, which is an outpatient status. That is why the outpatient thyroid surgery falls within the outpatient surgery in an outpatient hospital facility 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 outpatient thyroid surgery you had from April 16, 2021, to April 17, 2021 at an outpatient hospital facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.

You asked the Plan to pre-approve the additional PT visits. You say that you have been able to increase your mobility and range of motion with this treatment. You think that you should be allowed to continue therapy as it makes you feel better and you do not wish to take medication. The Plan denied your request. The Plan says additional visits are not needed to maintain your condition.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has been receiving PT for low back pain with 29 sessions being approved since March 2, 2021. The additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been instructed in home exercises. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay for knee arthroplasty for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not meet the criteria for an inpatient hospital stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is a 76 year old female with knee osteoarthritis who was admitted to the hospital for a scheduled non-emergent knee arthroplasty procedure. The enrollee has a past medical history of hypothyroidism and hyperlipidemia. The provided records do not show that the enrollee would require hospital services that would likely cross two midnights for this ambulatory procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay for knee arthroplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT code(s): 64493 and 64494), for the enrollee.
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says the notes do not show that the enrollee's prior injection helped the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our physician reviewer found the standard of care algorithm for facet pain is two (2) diagnostic blocks followed by RFA. Intra-articular injections as a series has been shown to be not efficacious. The enrollee has had only one (1) set of diagnostic facet blocks at different levels from the requested therapeutic injections and only one set of diagnostic blocks has been performed. A second set of diagnostic MBB is required before a therapeutic block. Therefore, the request is deemed 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT code(s): 64493 and 64494), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 1, 2021 to
February 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home
health services under a plan of treatment.
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x
TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from
February 1, 2021 to February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical extractions (D7210), bone grafts (D6104), surgical placement of implants (D6010), cone beam image capture (D0367) and a diagnostic consultation (D9310) provided on January 19, 2021, and January 22, 2021.
You asked the Plan to pay for the dental care. You say that this dental care was necessary after you experienced injury due to a fall and should be covered in full. The Plan denied your request. The Plan says these dental services are not covered by Medicare or by the Plan. Additionally, the provider in this case has opted-out of Original Medicare and does not accept Medicare payment.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for surgical extractions (D7210), bone grafts (D6104), surgical placement of implants (D6010), cone beam image capture (D0367) and a diagnostic consultation (D9310) provided on January 19, 2021, and January 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on April 24, 2021.
You asked the Plan to waive the copayment for emergency room visit. You say that the hospital put the wrong size catheter in you, so this visit was needed to put the correct size in. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $90 copayment for emergency room visit. You have been asked to pay $90 copayment for emergency room visit. Emergency room 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 for an emergency room visit provided on April 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 25, 2021 by an out-of-network (OON) provider.
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 rendered are not a covered 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 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 the laboratory services provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 21, 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 Current Procedural Terminology (CPT) code 87150 (11 Units) remains 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 87150 is "culture typing; identification by nucleic acid [DNA or RNA] probe, amplified probe technique, per culture or isolate, each organism probed." 

We find that CPT code 87150 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy services provided on March 5, 2021 by an out-of-network provider.

You asked the Plan to pay for chemotherapy administration (96413), injection, vedolizumab (J3380), normal saline solution (J7050) and Diphenhydramine hydrochloride (Q0163). You say that the care provided was reasonable and medically necessary. The Plan denied your request. The Plan says you did not request prior authorization as required.

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 items/services 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 chemotherapy services provided on March 5, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological medical examination and evaluation with initiation of a diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on April 9, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $40 copayment for in-network Medicare covered vision services at a specialist's office.
You have been asked to pay a $40 copayment for the in-network Medicare-covered vision service provided at a specialist's office. 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 medical examination and evaluation with initiation of a diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the presbyopia-correcting intraocular lens (P-C IOL) provided on May 11, 2021.
You asked the Plan to pay for the P-C IOL. You say that this will help you see better. The Plan denied your request. The Plan says that this is not covered.
The Plan must follow Medicare rules. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia-correcting intraocular lens (P-C IOL) provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).

You asked the Plan to pre-approve the MRI. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says medical necessity has not been established for the requested lumbar MRI.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not say that the enrollee has tried different ways to alleviate the pain for at least 6 weeks or that certain treatments are planned in the future. The review indicates that the requested MRI of the LS spine is not medically 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) spinal canal and contents (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care visit you had on March 5, 2021.

You asked the Plan to waive the copayment for the primary care visit. You say that you feel this service should be covered in full because you have been seeing this provider for two years and the claims have always been covered. The Plan denied your request. The Plan says the copayment was charged 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 $10 copayment for primary care visits. 

You have been asked to pay a $10 copayment for the primary care visit. 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 primary care visit you had on March 5, 2021.